See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/283894169

The Dynamic-Maturational Model of attachment and adaptation - Theory and

practice

Book · September 2014

CITATION READS

1 7,079

1 author:

Airi Hautamäki
University of Helsinki
38 PUBLICATIONS 491 CITATIONS

SEE PROFILE

All content following this page was uploaded by Airi Hautamäki on 16 November 2015.

The user has requested enhancement of the downloaded file.

The Dynamic-Maturational
Model of Attachment
and Adaptation
– Theory and Practice

Airi Hautamäki (Ed.)

SSKH Skrifter 37
Airi Hautamäki (Ed.)
SSKH Skrifter 36

Taitto: ADD – graafinen toimisto

Paino: Unigrafia

ISBN 978-952-10-8825-4
ISBN 978-952-10-8826-1 (PDF)
The dynamic-maturational model of attachment and adaptation –
theory and practice / Airi Hautamäki (Ed.). – Helsingfors : Svenska
social- och kommunalhögskolan vid Helsingfors universitet, 2014.
– SSKH Skrifter ; 37.

ISSN-L 1235-0966
ISSN 1235-0966 (Tryckt)
ISSN 2342-1312 (Online)
Contents
Preface................................................................................................5
Patricia M. Crittenden

Chapter 1: Transmission of attachment across three generations –

ghosts and angels in the Finnish Nursery....................................18
Airi Hautamäki

Treatment of family interaction and attachment relationships:

Clinical interventions based on the Dynamic-Maturational
Model (DMM)..........................................................................57
Bente Nilsen

Chapter 3: Psychotherapists’ and patients’ dispositional

representations of danger: Intervention planning using DMM
assessments.................................................................................72
Andrea Landini

Chapter 4: Endangered to endangering – how can the Modified

Adult Attachment Interview inform treatment in prison?.........102
Val Hawes

Chapter 5: The use of DMM assessments in court proceedings......129

Steve Farnfield
Preface

Patricia M. Crittenden, Ph.D.

Family Relations Institute
Miami, FL USA

When searching for a solution to a problem,

it is vital that the problem is carefully diagnosed.
It is only then that a solution can be considered.
If the diagnosis is wrong, no amount of solution will be effective.
Mawlana Faraz Ibn Adam, Dec. 1, 2011

This book joins a growing set of books and articles that mark a trans-
ition in the Dynamic-Maturational Model of Attachment and Adap-
tation (DMM) from describing developmental pathways to addres-
sing how to change pathways with psychotherapeutic treatment. At
long last, we are talking about possible solutions to psychological
and relationship distress. Put another way, the first generation of
work developed the developmental, psychological, and interperso-
nal model of protective strategies, some of which carried risk for
maladaptation. That task only took three decades. It was necessary
because the standard symptom-based diagnoses (DSM, ICD) were
not leading to improved treatment.
Now with a sound theory of developmental pathways and psy-
chopathology that addresses factors from genes and neurology to
psychology, relationships, and contexts, the second generation of re-
searchers and clinicians can focus on applying the DMM to healing
human suffering.

5
 The Beginnings and a Way to
Develop Knowledge
Let’s begin at the beginning. I want to look back to my work with
Mary Ainsworth and John Bowlby to consider the essential processes
that led to the DMM, in the hope that these processes might guide
us as we expand the DMM to treatment.
I remember the day in the spring of 1979 when Mary Ainsworth
sent John Bowlby to me - in the basement of Gilmer Hall at the Uni-
versity of Virginia where she had her attachment laboratory. Bowlby
and I sat together in a tiny, dark cubicle for a whole day looking at
my videotapes of mother-infant interaction. These videos were the
basis of my Master’s thesis on patterns of interaction that differenti-
ated abusing, neglecting, and adequate mother-infant dyads (Crit-
tenden, 1981). I showed Bowlby the videos of the mothers and ba-
bies with whom I had worked for the preceding three years. My task
was to figure out what these dyads did differently from other dyads.
It wasn’t such an easy task because, on the surface, they looked pretty
much like everyone else. The Big Discovery that I wanted to show
Bowlby was that the happiest dyads, the ones with the most smiles
and kisses, were the dyads in which the infant was abused. This dis-
crepancy became the basis for false positive affect. We both marveled
at the complexity – and clarity – of this unexpected finding. With-
out knowing it, the DMM was on its way, connecting behavior to
transformations of information.
For my doctoral dissertation, Ainsworth taught me the still largely
unknown Strange Situation. I applied it to a new kind of sample,
one with abused and neglected infants. It worked – and didn’t. A
few maltreated infants didn’t fit her ABC strategies. After careful
examination and re-examination of the videotapes, Ainsworth and
I agreed that these children used both Type A and Type C strategies
to fit the changing behavior of their dangerous mothers. Although
Mary Main later described some of the behaviors that these children
used as ‘disorganized’ (Main & Solomon, 1986), Ainsworth and I
thought the children were adapting to their dangerous and variable

6
circumstances (Crittenden, 1985; Crittenden & Ainsworth, 1989).
By 1994, this notion of new organizations (that Ainsworth had
not seen in her Baltimore sample of middle class, adequately reared
children) had expanded to the compulsive caregiving and compliant
(A3-4) and coercive aggressive and feigned helpless (C3-4) strategies
in 2-5 year-old children in the Preschool Assessment of Attachment
(PAA, Crittenden, 1992). Ainsworth’s insightful naming of the PAA
B3 strategy as ‘comfortable’ opened attachment theory to ideas about
arousal and to recognition that overly positive affect was uncomfort-
ably anxious. In my third sample, this time with entire families, we
saw that the siblings of maltreated children were adversely affected
by the family’s functioning (Jean-Gilles & Crittenden, 1990) and
that mothers and fathers often used opposite strategies, as did moth-
ers and their children (Crittenden, Partridge, & Claussen, 1991).
Ainsworth’s final contribution to the expansion of her ABC patterns
was to agree that there was a C5-6 pattern in the school years (Crit-
tenden, 1994). After that, I was on my own.
Well, not exactly. Colleagues in many countries helped to advance
attachment theory both to new cultural groups and also to older
ages. Airi Hautamäki was among the first to champion the emerging
DMM and her contributions to understanding cultural differences
and intergenerational transmission were powerful. She also helped
to validate the PAA and replicated and extended to three generations
the finding of opposite patterning between mothers and their first-
born children.
And so the DMM grew, one discrepancy at a time, one hunch
at a time, over three decades and with work in 22 countries until,
voilà!, we had a new diagnostic model of interpersonal strategic be-
havior and its underlying information processing, together with an
age-defined set of assessments. Finally, we were prepared to describe
psychological and relationship problems in ways that both social sci-
entists and neurologists could understand.

7
 But What Should a Clinician Do
with Attachment Theory?
Now that we have a descriptive model that addresses the sources and
processes underlying maladaptation, ‘DMM Integrated Treatment’
is being developed in the same way that DMM protective organiza-
tion developed. We are gathering and integrating the best ideas from
all theories and considering them, family by family, as they affect the
change process in families whose members suffer psychologically and
in their relationships. As always, we are looking for the unexpected,
for discrepancy.
There are several recent books that discuss using the DMM to
guide treatment. These include Attachment Narrative Therapy (Dal-
los, 2006), Raising parents: Attachment, parenting, and child safety
(Crittenden, 2008), Attachment-Based Practice with Adults: Under-
standing strategies and promoting positive change (Baim & Morrison,
2011), Attachment and family therapy (Crittenden, Dallos, Landini,
& Kozlowska, in press), Loving & learning: Promoting attachment
through baby play (Crittenden, in press).
In this volume, the authors address a wide range of applications
of DMM Integrated Treatment. Bente Nilsen writes about interven-
tion with families of young maltreated children. Andrea Landini
outlines principles of working with individual adolescents and adults
(beginning from a cognitive framework). Valerie Hawes describes
the process for incarcerated men who have been convicted of violent
crimes. The challenge in institutional settings is to treat the out-
come of broken attachments without any familial attachment fig-
ures. When everything breaks down, families go to court; Stephen
Farnfield describes the IASA Family Attachment Court Protocol
in terms of how to gather and structure information when family
courts need to consider family attachment in placement decisions
(cf., Crittenden, Farnfield, Landini, & Grey, 2013).
Although the topics seem quite divergent, DMM Integrated
Treatment has some commonalities that transcend specific applica-
tions such as these. Here I will describe briefly the recursive sequence

8
of steps that constitute DMM Integrated Treatment, as it has devel-
oped up to now.
The essentials. DMM Integrated Treatment has two bases: a re-
lationship between the individual(s) seeking treatment and their
therapist(s) and a set of information. These two bases develop to-
gether across the treatment, but are not the same thing. That is, some
models of treatment greatly emphasize the relationship, largely ex-
cluding systematic gathering and use of information. Other mod-
els emphasize information (usually the transfer of information from
therapist to individual), largely excluding the idea of a relationship
between the individual and therapist. The DMM treats the relation-
ship and use of information as equally essential to successful treat-
ment. Moreover, in the DMM, the primary flow of information is
from the individual to the therapist, with the therapist guiding the
individual to access and draw meaning from the information.
The focus and therapeutic function. DMM Integrated Treatment fo-
cuses on exposure to danger, both past and present. This gives DMM
Integrated Treatment more precision and efficiency than other forms
of treatment while still permitting all forms of treatment and treat-
ment techniques to be employed. Of course focusing on threat is
threatening and most people coming to treatment have not managed
such threats well in the past. That’s why they are in treatment. Help
is needed just to bring the topic up. In DMM Integrated Treatment,
the therapist functions as a transitional attachment figure, someone
who can regulate the intensity of the therapeutic experience, trying
to keep it in the individual(s)’ zone of proximal development. When
the therapist is successful, learning and change occur without the
opposite threats of boredom or overwhelming stress.
Assessment. That said, the information itself derives from a base
of careful clinical observation combined with systematic standard-
ized and validated assessment. Clinical observation includes aware-
ness of the individual’s appearance, patterns of movement, postures,
and gestures as well as the interpersonal process between the indi-
vidual and the therapist and among family members (if more than
one person is present). The reciprocal exchange of ideas and feelings
between each family member and the therapist is a major source of
relevant information. Using it, however, requires that the therapist

9
 knows him- or herself well. In DMM terms this is the therapist’s
protective strategy through which other individuals’ strategies are ex-
perienced. Other similar terms from other theories of therapy are the
therapeutic alliance or the transference/countertransference.
Formal assessment proceeds in three steps: delivering the assess-
ment which has its own impact on functioning (especially the Adult
Attachment Interview and the Transition to Adulthood Attachment
Interview), reviewing the assessment, and coding/classifying the as-
sessment. The complete process can take several weeks or even a few
months.
Family Functional Formulation. The clinical and structured sourc-
es of information are then combined with (1) individuals’ history
and that of their family members and (2) the observations, assess-
ments, and conclusions of other professionals to yield a more com-
plete picture of functioning called a Family Functional Formulation
(FFF). Even if one is treating an individual, ideas about family mem-
bers’ past and current relationships with the individual are crucial to
DMM Integrated Treatment (cf., Palmer, Nascimento, & Fonagy,
2013 on the advantages of family focused psychodynamic psycho-
therapy for children over child psychotherapy).
The functional formulation is the therapist’s working hypoth-
esis regarding the problem to be addressed in therapy, its genesis
and current state, and possible actions (including psychological ‘ac-
tions’) that could ameliorate the problem. In a nice ‘textbook case’,
the formulation is written in the case notes; this promotes clarity of
thought. Reality is less systematic. Whether written or only thought
about, the FFF is a constantly changing formulation. As more infor-
mation becomes available, the formulation is refined. As the ideas
in the formulation are tried in the therapy, the feedback informs the
reformulation.
Treatment. We’ve addressed the basis of treatment and its focus,
establishing a therapeutic relationship, assessment, and formulation.
Now it’s time for treatment, right? Wrong. The treatment is already
well under way! Already there have been a few meetings and a way
of working together has already been established. The individual(s)
coming for treatment probably didn’t notice that, but the therapist
should have been shaping their relationship purposefully from the

10
initial phone call to the first brief handshake through the sessions
that followed. As with other relationships, a way of being together
has been established – and it will be difficult to change it at this
point. In addition, the degree of challenge in the treatment is largely
known and self-protective strategies are in use – or not. We hope
they are not used regularly in the therapy, but instead are just needed
briefly – so they can be observed and discussed – without their be-
coming so dominant that exploration is curtailed by self-protection
(including dropping out of the treatment). Put another way, the
therapy may have phases in which layers of work are accomplished
successively (cf. Leenarts, et al., 2013). A particular advantage of
a planned phased treatment is that it can be implemented in sev-
eral parts, possibly even involving successive therapies as the family
members adapt to each set of changes. This, of course, is preferable
to repeated courses of treatment that are seen by family members
and therapists to have failed when the family dropped out.
Assuming that we have begun to establish a working therapeutic
relationship in which the therapist functions effectively as a transi-
tional attachment figure, and we have an assessment and formula-
tion, it is time to deal with ‘content.’ This involves two processes.
One is a recursive sequence of considering arousal, then unresolved
and still active trauma(s), then protective strategies. When arousal is
persistently low, it cannot motivate action (that is, the individual is
depressed). Until arousal is raised, the treatment is unlikely to be
successful. The possible ways of doing this include careful regula-
tion of the sessions by the therapist, teaching of self-managed arousal
regulation, and medication. Alternately, arousal may be excessively
high (for example, in the state of disorientation). Again, there are
several potential therapeutic actions to lower arousal.
When arousal can be maintained in a generally moderate range
(i.e., alert and comfortable), unresolved traumas can be considered.
The goal is to quiet the traumas sufficiently that more reflective ther-
apeutic work on the protective strategies can proceed.
When the strategies have been addressed, the individual(s)’ strate-
gies no longer so distort, exclude, falsify, deny, or delusionally gener-
ate imaginary information that the individual’s reality rarely overlaps
with other people’s understanding. This is the moment for reflection

11
 and integration. Of course, carrying out these three steps is a recur-
sive process, with unforeseen twists, turns, and returns.
The other approach to content involves considering what sorts of
therapeutic actions can implement the recursive sequence around
issues identified by the functional formulation. In DMM Integrated
Treatment, the therapeutic strategies will depend on whether the in-
dividual uses a Type A or Type C strategy (or both) and on which
transformations of information are used when the individual(s) are
distressed.
Testing treatment outcomes. A crucial part of treatment is evaluat-
ing outcomes. This can be done clinically or in controlled studies.
Clinically, in each treatment session, clinical actions are taken. Good
therapists attend to the outcomes of these actions as clearly as they
attended to their formulation and their moment-by-moment deci-
sions during the session. What was the effect of highlighting an im-
age? Of comparing preconscious sequences in different situations?
Of offering comfort? Or a challenge? Of asking for a conclusion? Of
waiting silently? By considering such questions following a session
and across sessions, therapists learn what functions well with each
person and family and what does not. This is clinical testing of out-
comes. Although therapists don’t always have time for such reflective
work, the best therapists teach themselves, person-by-person, to be
more effective by treating each therapy as a series of clinical trials.
That is quite different from what is happening in the field of psy-
chotherapy and intervention at large. In that context, evidence-based
treatment has become very important; this is, of course, an implicit
admission that most treatment is not sufficiently effective. Neverthe-
less, the huge literature on evidence-based treatment presents clini-
cians with serious problems. Most important is that studies of treat-
ment outcomes are rarely methodologically sound (cf. de Maat et al.,
2013; Crighton & Towl, 2007; Forman-Hoffman et al., 2013; So et
al., 2013); somewhere around 90% of ‘evidenced-based’ outcome
studies are seriously flawed and not a sound source of information.
Further, most address treatment packages, not individual treatment
actions; such studies cannot inform clinicians as to what part(s) of
the treatment was effective or whether some part was harmful (Lil-
ienfeld, 2007). By definition group comparisons provide averaged

12
data, but therapists work with specific people. How can a therapist
know whether the study is relevant to a specific person? The goal of
most reported studies is symptom reduction, but many therapists
want to improve relationships, overall adaptation, or information
processing. These therapists wonder whether reducing one symptom
might produce another. Given these limitations and without agree-
ment on the basis of dysfunction, on a focus on therapeutic actions,
and on more relevant measures of treatment outcomes for individu-
als, DMM Integrated Treatment cannot benefit greatly from this
body of knowledge.
These conditions send us back to the principles that I learned
from Bowlby and Ainsworth: focus on safety and reproduction, then
observe, describe, and attend to the unexpected, and finally change
what you understand and do. Repeat the process.
Although the application of treatment techniques to individuals
and their family members could be empirically based, at this point it
is not. We need studies of how different treatment actions affect peo-
ple with different patterns of arousal, different types of unresolved
traumas, and different protective strategies. Some actions might be
beneficial for almost everyone, whereas other actions might be ap-
propriate for specific subgroups. We need to think about how work
with one member of a family affects other members because what
helps one family member might create a burden for others. Yet even
if we were to have a hypothetical “Psychotherapists’ Desk Manual
for Effective Psychological and Relationship Treatment”, we would
still need to know what works, in what order, with each person with
whom we work. As with good parenting, the ‘manual’ must be devel-
oped out of sound principles applied uniquely to each child, to each
person in treatment. Effective DMM Integrated Treatment requires
a personalized and precise treatment plan, articulated in a family
context.

13
 Conclusions
Many people think of the Dynamic-Maturational Model of Attach-
ment and Adaptation as a brightly colored circular model, but that is
possibly the narrowest understanding of the DMM. At its heart, the
DMM is a way of looking a human distress and suffering that can
yield hope. What is the basis for that hope?

1. The human propensity to protect the self, one’s partner, and

one’s children – against all odds.
2. The elegance and advantage of our genetic heritage (rather than
presuming genes are the new devil, pestilence, etc.)
3. The basis of the DMM in our biology and maturation as a
species and our unique development as individuals.
4. A developmental etiology tied to dysfunction that reflects the
interaction of genes and experience in specific familial and
cultural contexts.
5. The close tie of the DMM diagnostic classifications to observed
behavior, such that each summative classification is unique to
the developmental experience of each person.
6. The ease with which people who suffer understand these DMM
‘diagnoses’ of what ails them.
7. The respect for adaptation, in all people and all cultures, as
opposed to seeing it as good genes or the fluke of good luck that
underlies childhood security.
8. The potential of humans to change when supported in
relationships, including those with therapists.
9. The enhanced possibility to test both diagnoses and theory
empirically and to revise them to better fit the evidence, i.e., the
dynamic quality of DMM theory.

The Dynamic-Maturational Model of Attachment and Adaptation is

a capacious theory. It is ready to grow as our knowledge base grows
and seeks validation through converging streams of information. At
its core, however, the DMM is a theory of hope. DMM theorists
understand that genes enable and make possible; they aren’t the de-

14
fective enemy that creates suffering. They understand that the beha-
vior that matters is interpersonal behavior and it is in interpersonal
behavior – or the lack of it - that suffering occurs. Intervention of all
kinds is inherently interpersonal because relationships are what need
to be healed. Most important the DMM is a theory of resilience,
one that is based in the human need for safety and comfort and our
possibilities to adapt to change. Security is wonderful; it’s an ideal.
Real life is made of challenges and our species is evolved to cope
with challenge. The DMM is a theory about growing and adapting;
its goal is reducing human suffering from the challenges that are
inherent in life.
This volume contains the growing edge of the DMM, with all
its variety, with its attention to different contexts and needs, and its
underlying coherence in the principles of adaptation and resilience
in the face of challenge.

15
 References
Mawlana Faraz Ibn Adam, www.daruliftaa.net, Dec. 1, 2011.
Baim, C., & Morrison, T. (2011). Attachment-based practice with adults:
Understanding strategies and promoting positive change. Brighton: Pavilion.
Crittenden, P.M. (1981). Abusing, neglecting, problematic, and adequate dyads:
Differentiating by patterns of interaction. Merrill Palmer Quarterly, 27, 1–18.
Crittenden, P.M. (1985). Social networks, quality of child rearing, and child
development. Child Development, 56, 1299–1313.
Crittenden, P.M. (1992). Quality of attachment in the preschool years. Development
and Psychopathology, 4, 209-241.
Crittenden, P.M. (1994). Peering into the black box: An exploratory treatise on the
development of self in young children. In D. Cicchetti & S. Toth (Eds.), Rochester
Symposium on Developmental Psychopathology, Vol. 5. The self and its disorders (pp. 79-
148). Rochester, NY: University of Rochester Press.
Crittenden, P. M. (2008). Raising parents: Attachment, parenting, and child safety.
Collumpton, UK: Routledge/Willan Publishing.
Crittenden, P.M., (in press). Loving & learning: Promoting attachment through baby
play. Hove, UK: Pavilion.
Crittenden, P.M. & Ainsworth M.D.S. (1989). Child maltreatment and attachment
theory. In D. Cicchetti and V. Carlson (Eds.), Handbook of child maltreatment, (pp.
432–463). New York: Cambridge University Press.
Crittenden, P. M., Dallos, R., Landini, A., & Kozlowska, K. (in press). Attachment
and family therapy. London: Open University Press.
Crittenden, P. M., Farnfield, S., Landini, A., & Grey, B. (2013). Assessing attachment
for family court decision-making. Journal of Forensic Practice, 15, 237-248.
Crittenden, P. M., & Landini, A. (2011). Assessing adult attachment: A Dynamic-
Maturational Method of discourse analysis. New York: Norton.
Crittenden, P.M., Partridge, M.F., & Claussen, A.H. (1991). Family patterns
of relationship in normative and dysfunctional families. Development and
Psychopathology, 3, 491-512.
Dallos, R. (2006). Attachment Narrative Therapy. New York: McGraw Hill.
de Maat, S., de Jonghe, F., de Kraker, R., Leichsenring, F., Abbass, A., Luyten, P.,
Barber, J.P., Van, R., & Dekker, J. (2013). The current state of the empirical evidence
for psychoanalysis: A meta-analytic approach. Harvard Review of Psychiatry, 21, 107-
137. DOI: 10.1097/HRP.0b013e318294f5fd.

16
Crighton, D., & Towl, G. (2007). Experimental interventions with sex offenders: A
brief review of their efficacy. Evidence-based Mental Health, 10, 35-37.
Forman-Hoffman, V. L., Zolotor, A. J., McKeeman, J. L., Blanco, R., Knauer, S. R.,
Lloyd, S. W., Fraser, J. G., & Viswanathan, M. (2013). Comparative effectiveness of
interventions for children exposed to nonrelational traumatic events. Pediatrics, 131,
526-539.
Jean Gilles, M., & Crittenden, P.M. (1990). Maltreating families: A look at siblings.
Family Relations, 39, 323–329.
Leenarts, L. E. W., Diehle, J., Doreleijers, T. A. H., Jansma, E. P., & Lindauer,
R. J. L. (2013). Evidence-based treatments for children with trauma-related
psychopathology as a result of childhood maltreatment: A systematic review. European
Child & Adolescent Psychiatry, 22, 269-283.
Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on
Psychological Science, 2, 53-70.
Palmer, R., Nascimento, L. N., & Fonagy, P. (2013). The state of the evidence base
for psychodynamic psychotherapy for children and adolescents. Child and Adolescent
Psychiatric Clinics of North America, 22, 149-214.
So, M., Yamaguchi, S., Hashimoto, S., Sado, M., Furukawa, T.A., & McCrone, P.
(2013). Is computerised CBT really helpful for adult depression? A meta-analytic
re-evaluation of CCBT for adult depression in terms of clinical implementation and
methodological validity. BMC Psychiatry, 13, 113.

17
 Chapter 1: Transmission
of attachment across three
generations – ghosts and
angels in the Finnish Nursery

Airi Hautamäki, Ph.D., professor of social

psychology and psychology, psychologist
Swedish School of Social Science, University
of Helsinki, Finland

Abstract
Studies have demonstrated the strong relation between adult attach-
ment security using the Adult Attachment Interview (AAI), and in-
fant security, using the Strange Situation Procedure (SSP). Benoit
& Parker (1994) found an inter-generational match between the
grandmother’s, mother’s AAI-classification and 1-year-old infant’s
attachment to his mother in the SSP. Because the greatest continuity
is found for secure attachment (Type B) and in middle class, stable
samples, continuity may be partly a function of the stabile socio-
economic context. The intergenerational transmission of attachment
is analyzed by theoretically exploring the differences between two
approaches in attachment research, the ABCD model, created by
Mary Main, and the DMM, created by Patricia Crittenden. The pre-
sent study both confirms and modifies the finding of Benoit and
Parker (1994) in a low-risk Finnish sample of 32 first-time mothers,
fathers and grandmothers that was followed from pregnancy until
the child was 3 years old. The AAIs were administered to mothers,

18
grandmothers and fathers during the third trimester of pregnancy
and the SSPs were performed, when the infant was at 12 months
with mothers, and 18 months with fathers. The Preschool Assess-
ment of Attachment (PAA) was conducted at 3 years for mothers and
fathers. Forty-seven percent of the 32 grandmother-mother-infant
triads had the corresponding attachment classifications. Log-linear
analysis showed that a complex model accounted for the transmis-
sion of attachment across three generations, when the children were
3 years. The results indicated continuity across three generations for
Type B (secure or balanced) and, partly, for Type A (avoidant), as
well as alternations from Type A to Type C (ambivalent-resistant or
threatening-disarming) and vice versa for insecure or anxious attach-
ment. The implications of the findings of a model of secure matches
and insecure meshes are discussed for theory development and fam-
ily intervention. The findings may help to guide treatment of trou-
bled mother-infant and father-infant by tailoring interventions to
include a focus on parental and infant dispositional representations
of themselves and ways of processing attachment-relevant informa-
tion in a three-generational perspective in order to better understand
the parental responses to infant behavior.

Keywords: transmission; attachment; three generations; the

ABCD model, the DMM

Corresponding author Airi Hautamäki, Swedish School of Social

Science, University of Helsinki, P.O. Box 16 (Snellmansgatan 16),
FI-00014 University of Helsinki airi.hautamaki@helsinki.fi

19
 The differing meanings of “organization” and “adjustment” in
attachment theory: Two paths diverge
With the help of the Strange Situation Procedure (SSP) Ainsworth
& Wittig (1969) established the three major ABC attachment pat-
terns among 11-12-month old children. The ABC classifications still
appear to account for the majority of middle-class infants also cross-
culturally (Main, 1990; Crittenden, 1995; Van IJzendoorn & Sagi-
Schwartz, 2008). In addition, Ainsworth and colleagues (Ainsworth,
Blehar, Waters, & Wall, 1978) found the predictive association be-
tween the maternal sensitivity during the first year of life and the
infant’s attachment pattern at 11 months in normative populations.
However, in risk populations many maltreated infants (Crittenden,
1985; Egeland & Sroufe, 1981) and 13% of infants in low-risk sam-
ples (Main & Solomon, 1990) could not be classified in accordance
with Ainsworth’s original classificatory model. In both atypical and
normative populations the risk was the over-assignment of uncertain
cases to the Type B. Two of Mary Ainsworth’s students, Mary Main
and Patricia Crittenden tried to resolve the problem by developing
new theoretical categories along with coding guidelines. The two ap-
proaches diverged in regard to the different meanings that Main and
Crittenden gave to two essential concepts in attachment theory that
is attachment organization and adaptation (Landa & Duschinsky,
2012, 2013). The intergenerational transmission of attachment is
analyzed by theoretically exploring the differences between the two
approaches.
Mary Main (Main & Solomon, 1990) expanded Ainsworth’s ABC
model by adding a fourth category called disorganized (Type D),
and, in addition, unresolved or cannot classify in adulthood (Hesse,
1996; Main & Hesse, 1990). Disorganization referred to conflicted
or anomalous proximity-seeking (e.g., stilling, freezing) behavior
during reunions in the Strange Situation, originally described in
a normative sample of 12-month old infants (Main & Solomon,
1990). This is termed the ABCD model. Crittenden elaborated an
information processing approach, the dynamic-maturational model,
termed the DMM that originated from Bowlby’s (1980) theory of
memory systems (Landa & Duschinsky, 2013). Patterns of attach-
ment are considered self-protective strategies. These self-protective

20
strategies are assumed to vary dimensionally, not categorically, in
terms of the relative use of cognitive-contingent versus affect-arous-
ing information to organize behavior (Crittenden, 2000a, 371): “...
the patterns are not categorical. To the contrary, they are best described
in terms of two dimensions: source of information (cognition and affect)
and degree of integration.” Crittenden (2006, 2008) proposed that
there are two basic components of human experience of danger, two
kinds of information: Cognitive information, that is, causally, tem-
porally or other sequentially ordered stimuli about the potential to
safety or danger, and affective information, the intensity of stimula-
tion pertaining to affect. The negative affect, anger, fear and desire
of comfort are provoked by the potential of danger. Individuals are
assumed to have not one stable working model of attachment, but
dynamically changing multiple representations based on different
processing pathways. Diverging dispositional representations, that
is, dispositions to act, regulate behavior in various situations. The
degree of integration among dispositional representations is the other
dimension in the DMM (Crittenden, 2006, 2008) (see Fig. 1). Crit-
tenden’s (1994) model is also attuned to the developmental changes
of attachment behavior and representations.

21
 Integrated True Information
True Cognition True Negative Affect
B3
B1–2 Comfortable B4–5
Reserved Reactive
A1–2 C1–2
Socially Facile/ Threatening/
Inhibited Disarming

Cognition A3–4 C3–4 False Cognition

(Type A) Compulsively Caregiving/ A/C Aggressive/
Compliant Feigned Helpless

A5–6 C5–6
Compulsively
Promiscuous/ Punitive/
Self-Reliant A7–8 Seductive
Delusional
Idealization/
C7–8
Externally Menacing/
Denied Negative Affect Assembled AC Paranoid Denied True Cognition
Self Psychopathy
Delusional Cognition Delusional Affect
Integrated Transformed Infomation

Figure 1: DMM self-protective strategies in adulthood (Copyright, P.M.

Crittenden, 2010)

Landa and Duschinsky (2013) stress that the basic argument between
Main’s ABCD and Crittenden’s DMM model is not Crittenden’s
rejection of the idea of attachment disorganization in infants, that
Crittenden would consider infants who express anomalous proximi-
ty-seeking only to be showing organized combinations of avoidant
and resistant attachment strategies (Van IJzendoorn, Schuengel, &
Bakermans-Kranenburg, 1999). In fact, Crittenden (2006, 2008)
uses the term of disorganization to denote a situation in which the
individual is not capable of processing and containing the emerging
strong negative affect with the help of his/her self-protective strategy.
Intrusion of forbidden negative affect is assumed to occur most pro-
bably with pervasively applied compulsive A strategies (Crittenden
& Landini, 2011). Landa & Duschinsky (2012, 2013) point out
that the crucial difference between the ABCD and the DMM lies in
the different interpretations of attachment organization in terms of the
set goals of the attachment system and adaptation.
Main (1977), following Ainsworth (1972), considered physical
proximity as the set goal of the attachment system, when the attach-

22
ment system is activated by stress. Therefore, behavior oriented at
physical proximity is organized. Reunion behaviors which showed
conflicted proximity seeking, in particular, a conflict between ap-
proach and avoidance, e.g., the infant approached his caregiver with
his head averted were considered disorganized (Main & Solomon,
1990). Crittenden (1984) followed Ainsworth’s (1990) later defini-
tion of organization. Ainsworth (1990) argued, on the basis of her
correspondence with Bowlby (Landa and Duschinsky, 2013) that
the proximity seeking may be a set goal of attachment at 11 months,
but in older children and adults the more general goal of the attach-
ment system is to maintain the availability of the caregiver. Like-
wise Crittenden (1992a,b, 1994, 1995) considered the protective
availability of the caregiver as the set goal of the attachment system,
when the attachment system is activated. She defined the term or-
ganized to include any patterned behavior aiming at maintaining
the protective availability of the caretaker. Thus, Ainsworth’s and
Crittenden’s definition expanded in a developmental psychological
sense the child’s secure base behavior, including both the infants’
predominantly physical proximity seeking and older children’s at-
tempts at maintaining the protective availability of his caregiver by
other means, too. Seemingly conflicted behavior, that was unclassifi-
able with Ainsworth’s ABC model, and was considered anomalous
proximity seeking behavior by the ABCD model, could be discerned
as a patterned strategy for maintaining the protective availability of
the caregiver, and consequently, as organized in Crittenden’s sense.
Main and Crittenden follow Bowlby (1969/1982) in their concep-
tualization of attachment as a means of the child to survive through
the early, most dangerous years of social, psychological and physi-
cal development. Landa and Duschinsky (2013) argue that Main
(1979) used the term adaptation in a more restricted sense, to ex-
plain why behavioral systems had evolved for the species. Proximity
seeking behavior was adaptive for humans in dangerous situations as
an expression of the adaptation of the species (Landa & Duschinsky,
2013, 328): “Behavioral breakdown at the level of an individual infant,
although it might indeed have some beneficial effects, was not perceived
by Main to not be an expression of a species level adaptation to achieve
proximity in conditions of perceived threat.” Crittenden appears to use

23
 the term adaptation more broadly, extending a species level adapta-
tion perspective to ontogenetic development that is, focusing on the
function of the infant’s behavior for maintaining the caregiver’s pro-
tective availability (Landa & Duschinsky, 2013) in order to survive
dangers of infancy. Whereas Main considered combinations of A and
C behavior as disorganized, representing a behavioral breakdown of
the infant’s coherent proximity-seeking strategy, Crittenden (1983)
saw those combinations as organized, that is functional adaptations
to complex, highly inconsistent, both abusive and neglectful fam-
ily relationships (Radke-Yarrow, 1998; Radke-Yarrow, Cummings,
Kuczynski, & Chapman, 1985). In addition to the survival func-
tion of attachment, Crittenden (1995, 2006) relates her theory to
reproductive fitness, as defined by Simpson & Belsky (2008, 132):
“`Reproductive fitness´ reflects the extent to which an individual’s genes
are in his or her descendants.”. DMM is a theory of both protecting
the self and one’s offspring from danger, and finding a reproductive
partner (Crittenden, 2006).
In defining attachment as a dynamic fit of strategy to context
Crittenden argues that no attachment pattern should be consid-
ered species-typical or primary. Early attachment theorists (Bowlby,
1969/1982, Ainsworth, 1979, Main, 1981) proposed that secure at-
tachment was nature’s prototype or species-typical. The early attachment
theorists probably relied too much on the questionable view that most
the child rearing environments of human hunter-gatherer ancestors in the
environment of evolutionary adaptedness (EEA) would have been uni-
formly benign and resource-rich (Simpson & Belsky, 2008).
The differences in the interpretation of the central concepts in
attachment theory, organization in terms of the set goals of the attach-
ment system as well as adaptation explain the diverging views on the
role of danger and perceived threat in the ABCD and the DMM
models. In contrast to the ABCD model, the DMM considers fear
to be a strong organizing affect fostering self-protection (Crittenden,
2006; see also LeDoux, 2002). Thus, endangered individuals would
show organized strategies that reflect more complex Type A and Type
C organizations (Crittenden, 1985; Crittenden & Ainsworth, 1989;
Crittenden & DiLalla, 1988; Radke-Yarrow et al., 1985), across the
lifespan and across generations.

24
 Fonagy (2013) states that Main’s position in the attachment field
has been supported by a considerable amount of empirical data and
experimental research referring to Van IJzendoorn & Bakermans-
Kranenburg’s (2008) meta-analytic studies, Weinfield, Sroufe,
Egeland, & Carlson’s (2008) summary of individual differences in
infant-caregiver attachment, and studies of the heritability of attach-
ment (Fearon et al., 2006). Crittenden’s theoretically more complex
model is based on less experimental research (see, however, Strat-
hearn, Iyengar, Fonagy, & Kim, 2012; Hautamäki, Hautamäki,
Neuvonen, & Maliniemi-Piispanen, 2010a,b). Hitherto, the two
coding systems have been compared only in a few studies (Crit-
tenden, Claussen, & Kozlowska, 2007; Crittenden & Newman,
2010; Shah, Fonagy, & Strathearn, 2010; Spieker & Crittenden,
2010). Results indicate that the DMM better differentiates risk cases
from non-risk cases. Within risk cases, the DMM is better at dif-
ferentiating cases on severity of disorder (Crittenden, Claussen, &
Kozlowska, 2007; Crittenden, Kozlowska, & Landini, 2010; Crit-
tenden & Newman, 2010; Spieker & Crittenden, 2010).
Crittenden (2008; see also Crittenden, Dallos, Landini, & Ko-
zlowska, in press) stresses that the DMM is a theory integrating
theoretical and empirical findings from different theoretical perspec-
tives, e.g., developmental psychology, the ecology of development,
developmental psychopathology, cognitive science and family sys-
tems theory. In line with Crittenden, Landa & Duschinsky (2013)
argue that the strength of the DMM more is in the way it offers
an integrated, theoretically interesting and up-to-date interpretive
framework than in its current empirical validity. The theoretical
complexity of Crittenden’s model, integrating both developmental
and neuropsychological as well as family systems theory has appealed
to clinicians as well as developmental psychologists. Critique against
the ABCD model has originated from developmental psychology
as well as developmental psychopathology. Thompson and Raikes
(2003) called for a new conceptualization of attachment built on
the notion of change of attachment patterns that should reflect the
input of maturation, of developmental processes, of context and cul-
ture referring to the DMM model. Rutter and colleagues (Rutter,
Kreppner, & Sonuga-Barke, 2009) argue that the notion disorgani-

25
 zation has not yet been sufficiently conceptually or empirically valid
in developmental psychopathology. Heterogeneous cases of risk may
be put into the single and crude disorganized/unresolved/cannot clas-
sify categories (Crittenden, 2010). Certainly, Fonagy (2013) is right
in pleading for a creative dialogue and building theoretical bridges
between the positions of Main and Crittenden. In the present arti-
cle, both positions are discussed in the formulation of problems and
interpretation of results.

Transmission of attachment across

three generations – continuity versus
discontinuity
Using the railway station metaphor, the developmental pathways
being the rails the baby embarks on, Bowlby (1980) argues that at-
tachment patterns once formed are biased towards constancy, but
could change, if the environment changed (Thompson & Raikes,
2003; Weinfield, Sroufe, & Egeland, 2000). The developmental
pathways may branch at expected times as a function of matura-
tion, and unexpectedly branch as an outcome of accommodation
(Crittenden, 2000b). Thus, Bowlby (1980) did not define develop-
mental pathways as linear and determined by their conditions, but
in probabilistic terms. The early writings on attachment security, as
assessed by the SSP stressed the lifespan continuity of attachment se-
curity within the Ainsworth attachment patterns (Hamilton, 2000;
Waters, Hamilton, & Weinfield, 2000). The long-term stability of
assessment of attachment security versus insecurity has been questio-
ned by findings from more recent longitudinal studies that extended
from infancy to adult life (Grossman, Grossman, & Waters, 2005;
Sroufe, Egeland, Carlson, & Collins, 2005). The lawful discontinuity
of attachment from early infancy to adulthood is related to environ-
mental change and risk. Stability is negatively related to risk factors,
and positively related to socioeconomic status (Belsky, Campbell,
Cohn, & Moore, 1996; Grossmann, Grossmann, & Kindler, 2005;
Thompson, Lamb, & Estes, 1982; Vondra, Hommerding, & Shaw,

26
1999; Vondra, Shaw, Swearingen, Cohen, & Owens, 2001; Wein-
field, Sroufe, & Egeland, 2000).
Crittenden’s (2000) approach is based on Bowlby’s (1980) think-
ing, and she argues that flexible adaptation is typical to human de-
velopment. The DMM addresses change and treats adaptation as a
dynamic fit of attachment strategy to context, that is, the relation
of the individual’s developing strategy to parental contingencies and
contextual dangers (Crittenden, 2006). Early conditions are not seen
as defining or limiting individual potential; the effect of maturation
creates possibilities for change in developmental pathways. In partic-
ular, when there is danger, the DMM predicts increasingly complex
organization across individuals’ development and across generations
(Crittenden, 2008). Thus, Crittenden (2000b) connects change with
the developmental opportunities offered by each maturational-de-
velopmental shift or, alternatively, changes in the environment re-
quiring accommodation of the child. Discourse analysis of the Adult
Attachment Interview protocols indicates that reorganizing respond-
ents are able to find and create new and coherent meaning around
discrepancies between information from different memory systems
(Crittenden & Landini, 2011).
The intergenerational transmission of attachment may be analysed
in these terms. In a meta-analysis of 661 dyads in 13 studies that
used both the Infant Strange Situation Procedure (SSP) (Ainsworth,
Blehar, Waters, & Wall, 1978) and the Adult Attachment Interview
(AAI) (Main, & Goldwyn, in press; Hesse, 1999), Van IJzendoorn
(1995a) found that 75% of mothers and infants had matching se-
cure (Type B) versus insecure (Types A and C) attachment patterns.
But when a four-way classification (secure, avoidant, ambivalent,
disorganized) was tested the match between mothers and infants
dropped to 63%, with even less agreement seen for the insecure
groups. Benoit and Parker (1994) studied the transmission of attach-
ment across three generations in a longitudinal study of 96 infants,
mothers and grandmothers with a stable middle-class background
across generations. They found an intergenerational match between
the grandmother’s and mother’s AAI-classification, and the 1-year-
old infant’s attachment to his mother in the SSP. Sixty-five percent
of the 77 grandmother-mother-infant triads had the corresponding

27
 attachment classifications. The secure classifications in the sample
accounted for almost all of the variance. Because the greatest stabil-
ity of attachment has been found in middle-class, stable samples,
continuity may be partly a function of socioeconomic context which
may permit a less dangerous and stressful family environment (Crit-
tenden, 2008). Thus, the continuity of attachment from mother to
infant is more robust for secure than insecure attachment. In addi-
tion, the mechanisms of transmission appear more complex than the
infant directly replicating his mother’s attachment strategy.

Hypothesis of less intergenerational

continuity and of secure matches and
insecure meshes
Benoit & Parker (1994) showed the cross-generational stability of
attachment in their study concerning middle- to upper-class fami-
lies, with a distribution of attachment status skewed towards secure
or autonomous attachment. The purpose was to replicate Benoit
& Parker’s study in a country in which the socioeconomic changes
across generations have been rapid (Ingold, 1997) and the amount of
secures appeared to be less (Cedercreutz & Silven, 1998; Moilanen,
Kunelius, Tirkkonen, & Crittenden, 2000; Nauha & Silven, 2000).1
The hypotheses of this study were:
- The continuity of attachment across generations would be less
than in the Benoit & Parker (1994) study.

1 Cederberg & Silvén (1998) and Nauha & Silvén (2000) did not transcribe the AAI
interviews verbatim. Instead they classified their video filmed AAI interviews. Ho-
wever, Hesse (1999, 2008) stresses that the coding procedure of the AAI is focused
on the overall coherence of the text in terms of Grice’s (1989) maxims. Because of
the predominance of Type A attachment (70%) among men, Cederberg and Silvén.
(1998) argued that the attachment classifications may be culturally contingent. In
their later studies, Silvén and colleagues (Kouvo & Silvén, 2010) have specified the
border, that is the differences between the more reserved secures (F1 and F2) and
persons classified as mildly dismissive (Ds3). However, if attachment is defined in
culture-specific ways, it is difficult to compare across cultures (Claussen & Critten-
den, 2000).

28
- Matches across 3 generations would be frequent within secure
attachment: Continuity of Type B classification across 3
generations.
- Meshes across 3 generations would be frequent within insecure
attachment: Type A strategy of grandmother -> Type C strategy
of mother -> Type A of child.

If an intergenerational continuity would be found using the DMM

thinking and assessments, it would be a strong claim for continui-
ty, because the DMM does not predict simple continuity, but the
individual’s flexible adaptation to respective context. Predictable de-
viations from continuity would show the range of human adaptation
(Shah, Fonagy, & Strathearn, 2010).

29
 Methods

Subjects and procedures

Two low-risk samples were followed from the pregnancy of the focal
child until the child was 3 years old. Inclusion criteria were that
the married or cohabiting couple was expecting their first child, the
expectant mother was at least 18 years old, and the maternal grand-
mother agreed to participate in the study. The volunteer samples
were enrolled through local, public maternity counselling offices,
part of the maternity welfare system in Finland. This service is provi-
ded to all expectant mothers in their local areas. Fifteen couples with
maternal grandmothers were recruited from a middle-sized town in
eastern Finland during one year. An additional 19 couples and ma-
ternal grandmothers were recruited from the four main maternity
counselling offices of the capital of Finland. The total sample con-
sisted of 34 mothers, their spouses (N=34), maternal grandmothers
(N=33), and firstborn children (N=34). None of the grandmothers
lived with their children. Nearly half of the couples were married
at the time of enrolment. (Hautamäki, Hautamäki, Neuvonen, &
Maliniemi-Piispanen, 2010a,b.)
When the focal child was 3 years of age, 73.5 % of the couples
were married, two cohabiting couples had split up, and the rest were
still cohabiting. The ages of the mothers approximated the mean age
at which women in Finland give birth to their first child (M=27.6;
SD=4.3). The infants were full-term, healthy new-borns, whose ges-
tational age ranged from 37-42 weeks (M=40.1 weeks; birth weight
range 2.4-4.4 kg, M=3.5 kg). Forty-one percent of the children were
male. The educational level of the mothers was higher than that of
their mothers (74.3 % compared to 27.3 % had university degrees;
Chi2=15.8, df=2, p<.001). Couples from relatively more stable mid-
dle-class backgrounds responded and expressed an interest in the
study and its results. The losses were two triads. One grandmother
died before the AAI was completed. One family moved to Sweden
and could not be reached, when child was three years. (Hautamäki,

30
Hautamäki, Neuvonen, & Maliniemi-Piispanen, 2010a,b.)
The Adult Attachment Interview (AAI) (Hesse, 1999; Crittenden
& Landini, 2011) was used to assess the attachment strategy in
mothers, fathers and grandmothers. The interviews were completed
in the subjects’ homes during the expectant mother’s third trimester
of pregnancy. The modified AAI included additional questions de-
signed to probe six memory systems (Crittenden & Landini, 2011;
Farnfield, Hautamäki, Nørbech, & Sahhar, 2010). After the birth
of the baby two home visits were made, at the child ages of 7 weeks
and 6 months. Parent-child interaction was video-filmed for CARE-
Index assessment (parental sensitivity, control, unresponsiveness,
and child cooperation, compulsivity, passivity) (Crittenden, 2007).
The Strange Situation Procedure (SSP) (Ainsworth et al., 1978) was
used to assess the attachment status in infants at 12 months, with
mother, and, at 18 months, with father. The Preschool Assessment
of Attachment (PAA) (Crittenden, 2004) was conducted, when the
child was 3 years, and the parents completed the CBCL (Achenbach
et al., 2000). The PAA is a modification of the Ainsworth infant clas-
sificatory procedure adapted to fit the more complex psychological
and interpersonal functioning of preoperational children. On the
basis of growing cognitive, language, and perspective taking abili-
ties, the child develops expectations of goal-corrected partnership.
The ambivalent-resistant, Type C pattern emerges, organized as a
coercive strategy. In coercing the parent, the child alternates between
sequences of coy-disarming and aggressive-threatening behaviour
(Crittenden, 1992a,b; Farnfield, Hautamäki, Nørbech, & Sahhar,
2010; Hautamäki, Hautamäki, Neuvonen, & Maliniemi-Piispanen,
2010a,b.)

Assessments
The assessment methods and coding procedures were in accordance
with Farnfield, Hautamäki, Nørbech, & Sahhar (2010). The coders
had been trained by Crittenden and the inter-rater reliability was
sufficient for each assessment method (Hautamäki, Hautamäki,
Neuvonen, & Maliniemi-Piispanen, 2010a,b). In the CARE-Index

31
 video clips (Crittenden, 2007) a tendency toward less eye contact
and shared joy could be seen. In the SSP (Ainsworth et al., 1978;
Crittenden, 2003) and the PAA (Crittenden, 2004) the quiet dyad
was frequent, characterized by scant physical contact and eye con-
tact, and the child sometimes appeared self-contained. In the AAI
transcripts, in particular, for men, a tendency toward inhibition of
affect via distanced and minimized discussions of childhood, for ex-
ample, lack of episodes and integrated or intense images, dismissal
of self, but not of others.

Results

The distribution of attachment strategies

Because of the small sample size and the comparison of the results
to those of Benoit and Parker, the 3-category system was used in
the statistical processing of data. It seemed warranted to include the
A+ and C+ classifications into their normative counterparts, as the
psychological function of the processing of attachment-relevant in-
formation was similar, that is, the hyper-activation of the attachment
system for the Type C, and the de-activation of the attachment sys-
tem for the Type A. Thus, for statistical analysis, the high-subscript
Type A and C classifications were collapsed into the 3-category sys-
tem for all the assessments classifications.
Even though the samples in the present study were drawn from a
normative population, the distributions of the attachment patterns
of the sample were biased toward Type A1-2 attachment, which was
particularly pronounced for fathers (64.7%), children at the age
of 3 (51.5%), and to some extent for the grandmothers (42.4%).
There was a lower than expected frequency of Type B attachments
for distributions of samples drawn from normative populations (van
IJzendoorn, & Sagi, 2008). The percentage of Type B was for fa-
thers=17.6%, grandmothers=24.2%, mothers=32.4%, children at 1
year=29.4%, and children at 3 years=27.3%. Thus, the assumption
of the numeric normativity of secure attachment was not supported

32
(Hautamäki, 2010). In line with Grossmann, Grossmann, Spangler,
Suess, & Unzner’s (1985) study (see also Grossmann, Grossmann, &
Kindler, 2005), the present study was an “outlier” in a cross-cultural
comparison. However, Ahnert, Meischner, & Schmidt’s (2000) East
German sample reflected the same distribution of attachment pat-
terns as those of the Bielefield study in West Germany.

Transmission of attachment across three

generations
The grandmothers’ AAI classification predicted significantly that of
her daughter, in 61% of cases using Bergman, & El-Khouri’s (1987)
person-oriented analysis EXACON (Hautamäki et al., 2010a).
The mother’s AAI classification during pregnancy predicted signi-
ficantly her 1-year-old infant’s SSP classification, in 76% of cases,
and her 3-year-old infant’s PAA classification, in 58% of cases. The
grandmother’s AAI classification predicted nearly significantly her
grandchild’s SSP classification at the age of 1 year, in 48% of cases,
and, significantly, that of her 3-year-old grandchild, in 72% of cases.
The father’s AAI classification predicted significantly both that of
his 1½ year-old, and that of his 3-year-old child, in 59% of cases.
There was moderate, but significant, stability of the children’s attach-
ment classifications from the SSP classification at 1 year to the PAA
classification at 3 years, in 61% of the cases. The highest stability
was linked to Type B and Type A classifications (Hautamäki et al.,
2010a,b).

A complex model of intergenerational

transmission of attachment
Forty-two percent of the 33 grandmother-mother-infant triads had
the corresponding attachment classifications, when the child was 1
year old. Forty-seven percent of the 32 grandmother-mother-infant
triads had the corresponding attachment classifications, when the
child was 3. Using log-linear analysis it was shown that a model of

33
 secure matches and insecure meshes accounted for the transmission
of attachment across three generations, when the children were three
years of age. In agreement with Benoit and Parker (1994), there was
continuity of Type B attachment across generations as predicted, and
to some extent, for Type A attachment. Thus, in spite of the cross-
cultural change of the external environment across generations (see
Ingold, 1997, for the swift transition from a rural to an urban way of
life in Finland), the Type B and, to some extent, Type A1-2 attach-
ment classifications were moderately stabile across three generations
at the child age of 3 (Hautamäki et al., 2010a). The Type A1-2 at-
tachment classification was also the predominant one in this study.
The increased skew towards the largest classification may increase
stability as a statistical artefact. Evidence was also found for reversal
patterning (meshing) across generations for Types A and C, the pen-
dulum swinging from Type A to C, and back to Type A, when the
child was 3 years (Hautamäki et al., 2010a,b). Using EXACON for
the analysis of single cells of 3×3 contingency tables with type-anti-
type classifications and frequency tabulations of the three-generation
combinations, both triads indicating continuity across three genera-
tions (B/B/B 22 % and A/A/A 19%) and reversal reactions (A/C/A
and C/A/C 22 %) were found (Hautamäki et al., 2010b).
Because this has been found in different samples (Crittenden et
al., 1991; Shah et al., 2010), a serious consideration is warranted.

Discussion

Pendulum swings across generations and reversal

parenting
The results indicate that if the lack of self-threatening danger is con-
stant, that is the parents feel safe, and they feel that they can exert an
influence on their environment they are likely to transmit their at-
tachment strategy to their child (secure match). But if there is danger
and/or the parents feel threatened, and they lack the possibility to

34
change their situation, their self-protective strategies may create a
threat to their child, who has to organize his attachment strategy
around this threat (insecure mesh). In terms of information proces-
sing Types A and C are psychologically opposite strategies. The focus
of individuals using them is on different aspects of the incoming sig-
nal that is temporal order for Type A or intensity of stimulation for
Type C. In particular, children of parents with high-subscript attach-
ment classifications, that is, A3-8 and C3-8 may have to organize
in reverse to the parent’s attachment strategy. In the present sample
high-subscript classifications were more frequent among the grand-
mothers (Hautamäki, 2010), many of whom had lived through the
World War II. If the parent has experienced danger and developed
a more extreme attachment strategy, she may through her way of
caring involuntarily create a threat to her child, who has to organize
his self-protective strategy around the threat. For example, an ea-
sily angered and potentially abusive mother may elicit a compulsive
compliant strategy in her child, who in her turn may not like to esta-
blish a hierarchic relationship to her child, and may be inconsistent
enough to raise a child, who uses a Type C strategy. Or a depressed
and withdrawn mother may elicit a compulsive caretaking strategy
in her child, who in her turn may be able to restrain anger in her own
child, and may raise a child, who uses a Type C strategy. (Hautamäki
et al., 2010b.)
In this study, low-subscript anxious attachment strategies also
produced reversals. The child appeared to develop a strategy that
fit the mother’s expectations by providing a missing piece to the in-
formation processing of his mother. In particular, this was typical
to reversal parenting (Crittenden & Landini, 2011). That is parents
expressed the wish in the AAI to be more available to their child than
their parents had been. The benevolent wish, stated on the semantic
level was not always enacted as factual sensitive behaviours to their
infants, as assessed by CARE-Index (Hautamäki, 2010). The permis-
sive or laissez-faire parenting reached Finland in the beginning of the
seventies. In the present sample already some of the grandparents
and several parents, who had been brought up in an authoritarian
way (Baumrind, 1993), liked to do the reverse with their own child.
They sometimes reared a child using the Type C strategy. (Hautamä-

35
 ki et al., 2010b.) In Finland the rejection of authoritarian parenting
started in the beginning of the seventies and resulted at times in that
parents using a Type A strategy tended to abdicate from their author-
ity and resort to laissez-faire education (Hautamäki, 2000; Kalliala,
2000). Figure 1 (vertical line: Availability and emotional sharing (up)
vs detachment (down); horizontal line: Authority: control via consistent,
explicit and negotiable rules (right) vs inconsistent context-bound rules
(left)) illustrates the pendulum swing from authoritarian parenting
to laissez-faire education. Baumrind (1993) states that an accumu-
lated body of parenting research indicates that the combination of
parental warmth and availability with parental authority bodes best
for the development of the child’s affective self-regulation as well
as social skills and cognitive abilities. Currently most Finnish par-
ents semantically state that they aim at authoritative parenting. They
wish to combine psychological availability, verbal give-and-take with
establishing an authority relationship with the child, coupled with
consistent age-adequate expectations (Hautamäki, 2000).

Figure 2: Parental psychological availability and parental control in com-

bination with probable developmental outcomes.

36
Reparation across generations
On the dyadic and family systems level, reversal parenting may be
considered an attempt at reparation (Tronick, 1989) that extends
across generations. Tronick (1989) defined reparation as the ability
of the dyad to repair breaches or breakdowns in their interaction.
In sensitive dyads breakdowns are repaired quickly and negative af-
fect is transformed into positive affect. That is, misunderstanding is
overcome by the return to the co-creation of shared meanings (Tro-
nic, 2008). However, some dyads show sustained periods when there
is either conflict or no connection accompanied by negative affect
(anger or withdrawal) (Hautamäki, 2014). If the mother-to-be has
experienced a dyad stuck in the condition of conflict or a detached
connection based on distorted meanings, her emerging awareness of
her earlier attachment relationships may be expressed in the bene-
volent wish of reversing the behavior of her own parent(s). Howe-
ver, this may not be easy to realize. In this study, some individuals
with low-subscript anxious attachment strategies also appeared to
produce reversals. A mother using the Type A strategy, who wanted
to be more available to her child and give the child the possibility
to express his feelings, may prioritize her child’s perspective in a way
that she is not able to establish an authority relationship to her child,
and may, in fact, encourage her child to use a Type C strategy. In
addition, as parents using a Type A strategy are uncomfortable with
physical and psychological intimacy, they may involuntarily become
inconsistent enough to raise C child. In this case the parent and the
child will frame their experience in very opposite ways and they act
on the basis of opposite attachment representations. If the parent
is not aware of this, it is difficult for her to elicit the responses she
desires from her child. Instead she may feel that her child behaves in
unexpected and exasperating ways that are difficult to understand.
Thus, parents’ semantically expressed well-meaning intentions and
responses in reversal parenting may backfire. (Hautamäki et al.,
2010b.)
When mother-child dyads and couples come to treatment, and the
meshing effect is found, one aspect of intervention is to enable the

37
 adults (mothers and partners) to recognize the strategy used by the
other person. This expands their own representational framework,
and they can use the information to organize a more adaptive re-
sponse, taking into account their points of agreement, while respect-
ing their individual differences. This is analogous to intra-psychically
reorganizing in the direction of Type B and this will yield a better ac-
cess to and balanced information processing of attachment-relevant
information for both dyads and couples. (Hautamäki et al., 2010b.)

Conceptual normativity of secure attachment

and some differences between the ABCD and the
DMM assessment methods
As the sample is small, the study is more exploratory than confir-
matory. The results should be generalized with caution. Small-scale
longitudinal attachment studies use time-consuming in-depth at-
tachment assessments that require extensive training. According to
Van IJzendoorn and Sagi (2008, 901) cross-cultural attachment re-
search rarely produces representative demographic data. The most
important contribution has been the test of core propositions of
attachment theory: “The cross-cultural studies have not (yet) refuted
the bold conjectures of attachment theory about the universality and
normativity of attachment, and about its antecedents and sequelae.”
In the present study the conceptual normativity of secure attachment
was not supported. The finding of the lower rates of Type B with the
DMM methods has been consistent across studies and ages (Critten-
den, 2000a,b; Crittenden, Claussen, & Kozlowska, 2007; Pleshkova,
& Muhamedrahimov, 2010; Shah, Fonagy, & Strathearn, 2010). Ho-
wever, the Ainsworth infant patterns are seen in the DMM as chang-
ing with maturation and adapting dynamically to the life contexts in
which children use them. Thus, the distribution of attachment strate-
gies in different cultural contexts is assumed to vary to promote adap-
tation to varied geopolitical and socio-cultural circumstances (Crit-
tenden, 2000a). This is in line with evolutionary psychologists arguing
that secure attachment does not constitute a norm in terms of adaptive
value across cultures (Simpson & Belsky, 2008).

38
 According to Grossman et al.’s (1985, 2005) results about a half of
the infants from a middle-class sample were classified as Type A, but
avoidant classifications did not necessarily predict psychopathology.
Although avoidant classifications have been a predictor of problems
in high-risk samples, they do not appear to be in low-risk samples
(Fagot, & Kavanagh, 1990; Fagot, & Pears, 1996; Greenberg, Speltz,
& DeKlyen, 1993). Grossmann et al. (2005) conclude that the high
proportion of avoidance in infancy in a middle-class sample made
the Bielefeld study an outlier in cross-cultural comparison, and argue
that the finding represented the impact of German patterns of child
care, i.e., a preference for early independence training. In the present
study, none of the parent ratings of their child on the CBCL fell into
the clinical range. The Type A1-2 and Type C1-2 attachment strat-
egies did not predict psychopathology as measured by the CBCL
(Hautamäki, 2010).
Ainsworth et al. (1978) connected Type A to maternal rejection
of infant signals. Crittenden, & Claussen (2000), looking at attach-
ment strategies in dimensional, rather than categorical terms, make
a distinction between a low-subscript Type A (A1-2) and a high-sub-
script, compulsive Type A (A3-A8), and contend that most children
classified as Type A1-2 do not show problems. Parents of Type A1-2
children offer sufficient protection, i.e., respond to the child’s nega-
tive affect (anger, fear, pleas for comfort), when it signals real dan-
ger, but consistently reject what seems to be “unnecessary” negative
affect, i.e., cries for comfort, fear or anger when the parents think
that the child actually is safe. The child learns to inhibit displays
of negative affect from processing and to act according to expected
consequences. He may become early independent in regard to affec-
tive self-regulation. But, in contrast to Type A+ strategies, Type A1-2
is only mildly dismissing of negative affect. In seriously threaten-
ing situations individuals using the A1-2 strategy can gain access to
the needed negative affect (Crittenden, 2006). The predominance of
Type A1-2 attachment agreed with earlier Finnish studies of low-risk
samples using the SSP and the AAI (Cedercreutz & Silven, 1998;
Nauha & Silven, 2000) and the PAA (Moilanen et al., 2000). (Hau-
tamäki et al., 2010a,b) The relatively low level (inept) of parental
sensitivity as assessed by the CARE-Index validated the predomi-

39
 nance of anxious attachment (Hautamäki, 2010). The level inept of
parental sensitivity was expressed by limited playfulness, unresolved
problems in regard to unresponsiveness, but no evidence of hostil-
ity (Crittenden, 2007). Also Kemppinen (2007) connected maternal
unresponsiveness among Finnish mothers with valuing quietness,
distal parenting and early independence (see Keller et al., 2004;
Moilanen et al., 2000).

Risks and strengths of avoidant attachment

– “Stand on your own ground and do not trust in
the help of strangers”
This is the inscription of the stone fortress, Sveaborg (The castle of
Sweden, the name originating from the time, when Finland was part
of Sweden), defending Helsinki against attacks from the sea. On the
basis of cultural requirements, the child selects a culturally operatio-
nal strategy from the universal repertoire of attachment behaviours
(Van IJzendoorn, & Sagi, 2008). Von der Lippe and Crittenden
(2000) argue that infants organize their attachment behaviours in
ways that increase the probability of their parents providing protec-
tion from dangers and comfort or decrease the probability of pa-
rents rejecting or harming the infant. Independence, self-reliance
and hard work have been required to survive the hard winters and
economic hardships on the scarcely populated rural areas in Fin-
land. The stress on cognition and the avoidant strategy with which
Finns have learnt to protect themselves against the invariant risk of
long winters and the variable risk of a difficult geopolitical position
may, however, create psychological risks, disorders related to a strong
inhibition of affect (Crittenden, 2000a). Individuals using a Type
A+ strategy, i.e., compulsive caregiving and compulsive compliance
inhibit affect firmly also under threat and even produce compelled
behaviour, role-reversing and obedient behaviour, respectively. If
a child cannot elicit protection from or terminate the anger of his
caregivers with these strategies, he may in adolescence retreat from
close relationships to either compulsive self-reliance (A6) or engage
in socially and/or sexually compulsive promiscuity (A5) (Crittenden,

40
2006). Depression is one danger of the over-inhibition of negative
affect (Type A+), as well as unexpected violence as a result of intru-
ded unrestrained negative affect, for example, in the context of high
stress coupled with alcohol (ab)use (Crittenden, 2000a).
In this study, gaze aversion was observed among 6-7-week-old ba-
bies. Schore (1994, 280) looks at the adaptive function of averting
the eyes. The infant avoids the registration of the inexpressive, flat or
negative facial displays of the caregiver to avoid processing the stress-
inducing message: “… the avoidant pattern precludes the vacillating
affective distress and anger associated with directing the attachment need
(the need for affective regulation) toward the psychologically unavailable
mother.” Thus, gaze aversion can in terms of Schore (1994, 379) be
considered an external manifestation of shame. Schore (1994) argues,
using Bowlby’s (1969/1982) classic model on sequential responses to
physical separations that the infant may gradually shift from a sym-
pathetic-dominant distress state, protest, towards a parasympathetic-
dominant state, despair. Gradually, the caregiver’s lacking ability to
respond, to regulate, and to stimulate sufficiently the infant’s arousal
states may lead to a relative deactivation of the infant’s attachment
system by excluding from processing socio-emotional stimuli that
activate attachment behaviour (Schore, 1994) or in terms of Crit-
tenden (2008), negative affect, that is, fear, anger and bids for com-
fort. A system to cope with heightened levels of sympathetic arousal
and stimulation may not fully evolve coupled to the risk of over-
controlled developmental psychopathologies (Schore, 1994), as well
as affect overload and affect intrusions, when stress overly rises (Crit-
tenden, 2008).
Analogously, Winnicott (1971/1997, 112) poses the question:
What does a baby see, when he looks at his mother’s face: “… what
the baby sees is himself or herself… In other words the mother is looking
at the baby and what she looks like is related to what she sees there…I
can make my point by going straight over to the case of the baby whose
mother reflects her own mood or, worse still, the rigidity of her own
defences. In such a case what does the baby see?” Maternal mirroring is
rooted in the mother’s feeling about herself with her baby and the
sense and meaning she is able to create about her baby and herself
as a mother. Winnicott (1971/1997) relates distorted maternal mir-

41
 roring of her baby to the risk of a compliant false self-organization
emerging in the baby.
The stress on cognition and temporal (if-then, when-then) con-
tingencies also represent traditional strengths in Finnish child rear-
ing. Finnish children grow up in socially safe environment, in which
children can be granted early autonomy. Early independence of chil-
dren has been valued in Finland and still is (Crittenden, & Claus-
sen, 2000). Children’s independence is also enhanced by the mother-
infant separation due to maternal full-time employment (Moilanen,
Kunelius, Tirkkonen, & Crittenden, 2000). The aim of the Nor-
dic and the Finnish welfare state has been to create predictable and
socially equal environments for families to bring up their children,
with long maternity leaves, that also can be shared by mother with
the father, and quality day-care accessible for all families. An equal
school system with well-trained teachers that holds high expecta-
tions for all children and believes in them has been created. Finnish
pupils have been and still are high performers in PISA (Programme
for International Student Assessment), characterized by the mastery
of thinking and commitment to learning (Hautamäki et al., 2008).

Are results got with the ABCD and DMM

methods comparable?
In order to avoid confounding culture and methods a crucial ques-
tion is, whether the DMM methods are comparable to other assess-
ment methods of attachment. The ABCD and the DMM systems
overlap most in regard to the normative A-B-C range. Comparisons
between studies using low-risk samples seem warranted. The DMM
methods are, however, more sensitive to the self-protective function
of attachment strategies, and, thereby, apt to differentiate attachment
strategies of more endangered groups (Crittenden, Claussen, & Koz-
lowska, 2007; Crittenden, Kozlowska, & Landini, 2010; Critten-
den & Newman, 2010; Spieker & Crittenden, 2010). According to
Black et al. (2000), up to 20% of a normative sample may have AAI
transcripts that need the additional sub-pattern classifications from
the DMM. In the Main and Goldwyn system, most non-normative

42
AAI transcripts may fall into four classifications E3, U/E3, U or CC
(Crittenden & Landini, 2011). Some non-normative transcripts, for
example, Type A3-4 transcripts, may even be assigned to Type B,
as the ABCD system does not make a distinction between episodes
told from the interviewee’s own perspective and those of significant
others. Similarly, the Ds2 category (dismissal, even derogation of the
other) in the ABCD system is considered avoidant. Even though the
dismissal and even derogation of self is associated with Type A in
the DMM system, the derogation of others is connected to Type C+
classifications, in particular, C5-6. In this study, the DMM extensi-
ons of the AAI made it possible to classify every AAI transcript in the
study. (Hautamäki et al., 2010a.)
Because the classificatory system of the PAA covers a wider range
of non-verbal enacted behaviours, indicative of coping with an inse-
cure and anxious attachment relationship, more children are classi-
fied as insecurely attached in the PAA than in the Ainsworth ABC or
the ABCD (Main, & Solomon, 1990) systems. Rauh, Ziegenhain,
Muller, & Wijnroks (2000) compared the ABC, the ABCD and the
PAA attachment assessments of 18 months to 21 months old low-
risk children. Even though there were differences in infant classifica-
tions, the systems also overlapped in their low-risk sample. Infants
identified as secure according to the developmentally and clinically
more refined PAA system were also classified as securely attached
in the Ainsworth ABC and Main ABCD system. Analogously, chil-
dren identified as insecurely attached in the ABC or ABCD system
were classified as insecurely attached in the PAA. (Hautamäki et al.,
2010a.)

43
 Most parents do not know most of the times what
they are doing – how to bridge the gap between
semantically stated well-meaning intentions and
procedurally enacted behaviour?
Early attachment transactions are imprinted in the baby’s procedural
and imaged memory (Crittenden, 2006, 2008; Farnfield, Hauta-
mäki, Nørbech, & Sahhar, 2010) as dispositional representations,
dispositions to act, and they encode coping strategies for affect re-
gulation, in particular, how to maintain basic affective regulation,
when stress rises. These pre-verbal procedural and the imaged dispo-
sitional representations act at levels that are beneath conscious awa-
reness ( Schore, 1994). When a child is born, a polyphony of beha-
viours of both ghosts (Fraiberg et al., 1975) and angels (Lieberman
et al., 2005), which have been encoded in the parents’ procedural
and imaged memory from their own childhood and nurseries are
aroused and stimulated to act through them. Fraiberg et al. (1975)
uses the fairy-tale the Sleeping Beauty as a metaphor, and refer to
the ghosts in every nursery, who are the late visitors from the unre-
membered past of the parents. Even though they are not invited to
the christening of the child, they appear as the uninvited guests at
the party. Fraiberg et al. (1975) argue that parents may enact with
their children dangerous scenes from their own early relational expe-
riences of danger, fear, anger and helplessness, thereby transmitting
to their child maltreatment from one generation to the next. Early
experiences of feeling unprotected and uncomforted are particularly
difficult to assimilate in a self-protective strategy (Crittenden, 2008).
When elicited by relevant stimuli, these dormant, not verbalized and
unremembered experiences of abuse and neglect may interfere with
subsequent functioning in the form of unresolved traumas. In these
situations, the individual’s protective functioning is more influenced
by his past experiences, that is, the compulsion to repeat responses
from the past in the present, which creates a potential for distorted
information processing and current maladaptive responses.
Attachment theory stresses the function of the interventionist and
therapist as a secure base. Lieberman, Padron, Van Horn, & Har-

44
ris (2005) argue that is crucial for the parent to recover a connec-
tion with receiving early care characterized by an intense and shared
positive affect between the parent and the child, in which she felt
understood, accepted, and worthy of love. This kind of identifica-
tion with the protector may interrupt the cycle of maltreatment. In
Zuckerman & Zuckerman’s (2005) terms, as a ghost buster, the task
of the interventionist is to give also the angels of the past a voice, to
elicit early memories of angel’s kisses, specific memories of parents be-
ing nurtured themselves. This will support parents’ nurturing behav-
ior, especially in the face of ghosts and shark music (Zanetti, Powell,
Cooper, & Hoffman, 2011), played crescendo, when negative affect
connected to past experiences of feeling unprotected, neglected or
abused, or uncomforted, rejected and unloved, is aroused. Reviving
memories of being held may help the parents to develop behaviors of
sensitive availability that promote a more balanced (in terms of using
all kinds of information, Crittenden, 2006) self-protective strategy
in themselves and their child.
Any treatment strategy should help the parents and the children
to develop access to a wider range of information in terms of dif-
ferent memory systems, which will help them to integrate in novel
ways (Crittenden, 2008). In terms of the classic question of Fonagy,
Target, Cottrell, Phillips and Kurtz’ (2002): What works for whom,
the treatment strategy could be chosen by taking into account the
attachment strategies of the dyad or in the family. Very inhibited
individuals with a Type A+ attachment strategy try to deny their own
suffering, their anger and their need for comfort, and they attempt to
function more independently in ways they cannot. Highly coercive
individuals using a Type C+ strategy may appear invulnerable and
deny their own contributions to how their attachment relationships
evolve. They exaggerate their displays of negative affect to obtain at-
tention and appear to have severe behavior problems (Kwako, Noll,
Putnam, & Trickett, 2010). Interventionists should intervene with
treatment strategies that are opposite to the individual’s way of pro-
cessing attachment-relevant information. Denied needs for comfort,
dependency needs as well as anger should be explored in highly self-
reliant individuals. Fostering self-regulative abilities is a high-priority
treatment issue in individuals using a coercive strategy (Kwako, Noll,

45
 Putnam, & Trickett, 2010). This may help parents to integrate in
novel ways helping them to make true their well-meaning intentions
and wishes in their procedurally enacted behavior with their child.

Acknowledgments
This research was supported by the Academy of Finland, University
of Eastern Finland, and University of Helsinki. We also like to thank
the participants in the study.

46
LITERATURE
Achenbach, T.M., & Rescorla, L.A. (2000). Manual for the ASEBA Preschool Forms
& Profiles. Burlington, VT: University of Vermont, Research Center for Children,
Youth, & Families.
Ahnert, L., Meishner, T., & Schmidt, A. (2000). Maternal sensitivity and attachment
in East German and Russian family networks. In P.M. Crittenden, & A.H. Claussen
(Eds.), The organization of attachment relationships. Maturation, culture and context
(pp. 61-74). Cambridge: Cambridge University Press.
Ainsworth , M. (1972). Attachment and dependency: A comparison. In J. Gewirtz
(Ed.), Attachment and dependency (pp. 97-137). Washington DC: Winston.
Ainsworth, M. (1979). Infant-mother attachment. American Psychologist, 34, 932-
937.
Ainsworth , M. (1990). Epilogue. In M.T. Greenberg, D. Cicchetti, & E.M.
Cummings (Eds.) Attachment in preschool years (pp. 463-488). Chicago: Chicago
University Press.
Ainsworth, M.. Bell, S.M., & Stayton, D.D. (1974). Infant-mother attachment
and social development: “Socialization” as a product of reciprocal responsiveness to
signals. In M.P.M. Richards (Ed.), Integration of the child into a social world (pp. 99-
135). Cambridge: Cambridge University Press.
Ainsworth, M., Blehar, M.C., Waters, E., & Wall, S. (1978). Patterns of attachment:
A psychological study of the strange situation. Hillsdale, NJ: Lawrence Erlbaum.
Ainsworth, M., & Wittig, B. (1969). Attachment and exploratory behavior of one-
year-olds in a strange situation. In B. Foss (Ed.), Determinants of infant behavior. Vol.
4 (pp.113-136). London: Methuen.
Baumrind, D. (1993). The average expectable environment is not good enough: A
response to Scarr. Child Development, 64, 1299-1317.
Belsky, J., Campbell, S.B., Cohn, J.F., & Moore, G. (1996). Instability of infant-
parent attachment security. Developmental Psychology, 32, 921-924.
Benoit, D., & Parker, K. (1994). Stability and transmission of attachment across
three generations. Child Development, 65, 1444-1456.
Bergman, L.R., & El-Khouri, B. (1987). EXACON – A FORTRAN 77 Program for
the exact analysis of single cells in a contingency table. Educational and Psychological
Measurement, 47, 155-161.
Bergman, L.R., & El-Khouri, B. (2002). SLEIPNER – a statistical package for pattern-
oriented analyses. Department of Psychology, Stockholm University, loaded 2.1. 2002.
Black, K. A., Jaeger, E., McCartney, K., & Crittenden, P. M. (2000). Attachment

47
 models, peer interaction behavior, and feelings about the self: Indications of
maladjustment in Dismissing/Preoccupied (Ds/E) adolescents. In P.M. Crittenden,
& A.H. Claussen (Eds.), The organization of attachment relationships: Maturation,
context, and culture (pp. 300-324). Cambridge: Cambridge University Press.
Bokhorst, C.L., Bakermans-Kranenburg, M.J., Fearon, R.M.P., Van IJzendoorn,
M.H., Fonagy, P., & Schuengel, C. (2003). The importance of shared environment
in mother-infant attachment security: A behavioral genetic study. Child Development,
74, 1769-1782.
Bowlby, J. (1969/1982). Attachment and loss: Attachment. Vol. 1. London: Hogarth
Press. (Original work published 1969).
Bowlby, J. (1973/1978). Attachment and loss: Separation: Anxiety and anger. Vol. 2.
Harmondsworth, Middlesex: Penguin Books. (Original work published 1973).
Bowlby, J. (1980). Attachment and loss: Loss, sadness and depression. Vol. 3. New York:
Basic Books.
Cedercreutz, J., & Silvén, M. (1998). Finländska mäns anknytningsstilar och deras
inverkan på sensitiviteten. Psykologia, 33, 430-443.
Claussen, A.H.. & Crittenden, P.M. (2000). Maternal sensitivity. In P.M. Crittenden,
& A.H. Claussen (Eds.). The organization of attachment relationships. Maturation,
culture and context (pp. 115–122). Cambridge: Cambridge University Press.
Crittenden, P.M. (1985). Social networks, quality of child rearing, and child
development. Child Development, 56, 1299-1313.
Crittenden, P.M. (1992a). Treatment of anxious attachment in infancy and early
childhood. Development and Psychopathology, 4, 575-602.
Crittenden, P.M. (1992b). Quality of attachment in the preschool years. Development
and Psychopathology, 4, 209-241.
Crittenden, P.M. (1994). Peering into the black box: An exploratory treatise on the
development of self in young children. In D. Cicchetti, & S.L. Toth (Eds.), Disorders
and dysfunctions of the self. Rochester Symposium of Developmental Psychopathology. Vol.
5 (pp. 79-148). Rochester, NY: University of Rochester Press.
Crittenden, P.M. (1995). Attachment and psychopathology. In S. Goldberg, R.
Muir, & J. Kerr (Eds.), John Bowlby’s attachment theory: Historical, clinical, and social
significance (pp. 367-406). New York: Analytical Press.
Crittenden, P.M. (1999). Danger and development: The organization of self-
protective strategies. In J.I. Vondra, & D. Barnett (Eds.), Atypical attachment in
infancy and early childhood among children at developmental risk. Monographs of the
Society for Research in Child Development, 64, 145-171 8 [3, Serial No. 258].
Crittenden, P.M. (2000a). A dynamic-maturational exploration of the meaning of
security and adaptation. Empirical, cultural and theoretical considerations. In P.M.

48
Crittenden, & A.H. Claussen (Eds.), The organization of attachment relationships.
Maturation, culture and context (pp. 358-383). Cambridge: Cambridge University
Press.
Crittenden, P.M. (2000b). A dynamic-maturational approach to continuity and
change in pattern of attachment. In P.M. Crittenden, & A.H. Claussen (Eds.), The
organization of attachment relationships. Maturation, culture and context (pp. 343-357).
Cambridge: Cambridge University Press.
Crittenden, P.M. (2003). A guide to expansions and modifications of the Ainsworth
Infant Strange Situation. Unpublished manuscript. Family Relations Institute, Miami,
Florida: May, 2003.
Crittenden, P.M. (2004). The Preschool Assessment of Attachment. Coding manual.
Family Relations Institute, Miami, Florida: December, 2004.
Crittenden, P.M. (2007). CARE-Index. Infants. Coding Manual. Family Relations
Institute, Miami, Florida: July, 2007.
Crittenden, P.M. (2006). A Dynamic-Maturational Model of attachment. Australia
and New Zealand Journal of Family Therapy, 27, 105-115.
Crittenden, P.M. (2008). Raising parents. Attachment, parenting and child safety.
Cullompton, Devon: Willan Publishing.
Crittenden, P.M. (2010). Preface: Pathways forward. Clinical Child Psychology and
Psychiatry, 15(3), 299-301.
Crittenden, P.M., & Ainsworth, M. (1989). Child maltreatment and attachment
theory. In D. Cicchetti, & V. Carlson (Eds.), Handbook of child maltreatment (pp.
432-463). New York: Cambridge University Press.
Crittenden, P.M., & Claussen, A.H. (2000). Adaptation to varied environments.
In P.M. Crittenden, & A.H. Claussen (Eds.). The organization of attachment
relationships. Maturation, culture and context (pp. 234-248). Cambridge: Cambridge
University Press.
Crittenden, P.M., Claussen, A., & Kozlowska, K. (2007). Choosing a valid
assessment of attachment for clinical use: A comparative study. Australia and New
Zealand Journal of Family Therapy, 28, 78-87.
Crittenden, P. M., Dallos, R., Landini, A., & Kozlowska, K. (in press).
Attachment and family therapy. London: Open University Press.
Crittenden, P.M., & DiLalla, D.L. (1988). Compulsive compliance: The
development of an inhibitory coping strategy in infancy. Journal of Abnormal Child
Psychology, 16, 585-599.
Crittenden,P.M., Kozlowska, K., & Landini, A. (2010). Assessing attachment in
school-age children. Clinical Child Psychology and Psychiatry, 15(2), 185-208.
Crittenden, P.M., & Landini, A. (2011). Assessing adult attachment: A dynamic-

49
 maturational approach to discourse analysis. New York: Norton.
Crittenden, P.M., & Newman, L. (2010). Comparing models of borderline
personality disorder: Mothers’ experience, self-protective strategies, and dispositional
representations. Clinical Child Psychology and Psychiatry, 15(3), 433-451.
Egeland, B., & Sroufe, L.A. (1981). Developmental sequelae of maltreatment in
infancy. In R. Rizley, & D. Cicchetti (Eds.), Developmental perspectives on child
maltreatment. San Francisco: Jossey Bass.
Fagot, B.I., & Pears, K. (1996). Changes in attachment during the third year:
Consequences and predictions. Development and Psychopathology, 8, 325-344.
Fagot, B.I., & Kavanagh, K. (1990). The prediction of antisocial behavior from
avoidant attachment classifications. Child Development, 61, 864-873.
Farnfield, S., Hautamäki, A., Nørbech, P., & Sahhar, N. (2010). DMM assessments
of attachment and adaptation: Procedures, validity and utility. Clinical Child
Psychology and Psychiatry, 15(3), 313-328.
Fearon, R.M.P., Van IJzendoorn, M.H., Fonagy, P., Bakermans-Kranenburg,
M.J., Schuengel, C., & Bokhorst, C. (2006). In search of shared and non-shared
environmental factors in security of attachment: A behavior-genetic study of the
association between sensitivity and attachment security. Developmental Psychology, 42,
1026-1040.
Fonagy, P. (2013). Commentary on “Letters from Ainsworth: Contesting the
`organization´ of attachment.” Journal of the Canadian Academy of Child and
Adolescent Psychiatry, 22(2), 178-179.
Fonagy, P., Target, M., Cottrell, D., Phillips, J., & Kurtz, Z. (2002). What works for
whom? A critical review of treatments for children and adolescents. New York: Guilford.
Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A
psychoanalytic approach to the problem of impaired infant-mother relationships.
Journal of American Academy of Child Psychiatry, 14, 387-421.
Greenberg, M.T., Speltz, M.L., & DeKlyen, M. (1993). The role of attachment in the
early development of disruptive behavior problems. Development and Psychopathology,
5, 191-213.
Grice, H.P. (1989). Studies in the way of words. Cambridge: Harvard University Press.
Grossmann, K., Grossmann, K.E., Spangler, G., Suess, G., & Unzner, L. (1985).
Maternal sensitivity and the newborn’s orientation responses as related to quality of
attachment in northern Germany. In I. Bretherton, & E. Waters (Eds.), Growing
points of attachment theory and research. Monographs of the Society for Research in Child
Development, 50 (1-2, Serial No. 209), 233-256.
Grossman, K.E., Grossman, K., & Waters, E. (2005).(Eds.), Attachment from infancy
to adulthood. The major longitudinal studies. New York, London: Guilford.

50
Grossmann, K.E., Grossmann, K., & Kindler, H. (2005). Early care and the roots
of attachment and partnership representations. The Bielefield and Regensburg
Longitudinal Studies. In K.E. Grossman, K. Grossman, & E. Waters (Eds.),
Attachment from infancy to adulthood. The major longitudinal studies (pp. 98-136).
New York, London: Guilford.
Hamilton, C.E. ( 2000). Continuity and discontinuity of attachment from infancy
through adolescence. Child Development, 71, 690-694.
Hautamäki, A. (2000). The matrix of relationships in the Late Modern family in
the Nordic countries: A haven in a heartless world, a disturbed nest or a secure base.
In A. Hautamäki (Ed.), Emergent trendes in early childhood education – towards an
ecological and psychohistorical analysis of quality (pp. 33-121). University of Helsinki,
Department of Teacher Education, Research Reports 216.
Hautamäki, A. (2014). Mother and infants: Screening for maternal relationships at
risk with the CARE-Index. In P. Holmes & S. Farnfield (Eds.), Guide Book to The
Routledge Handbook to Attachment: Intervention. London: Routledge.
Hautamäki, A. (2010). Attachment and parental sensitivity in a low-risk Finnish
sample – The avoidant and unresponsive Finns? In P. Aunio, M. Jahnukainen, M.
Kalland, & J. Silvonen (Eds.), Piaget is dead, Vygotsky is still alive, or? A Book in
Honour of Professors Airi and Jarkko Hautamäki (pp. 149-182). Finnish Educational
Research Association: Research in Educational Sciences.
Hautamäki, A., Hautamäki, L., Neuvonen, L., & Maliniemi-Piispanen, S.
(2010a). Transmission of attachment across three generations. European Journal of
Developmental Psychology, 7(5), 618-634.
Hautamäki, A., Hautamäki, L., Neuvonen, L., & Maliniemi-Piispanen, S. (2010b).
Transmission of attachment across three generations: Continuity and reversal.
Clinical Child Psychology and Psychiatry, 15(3), 347-354.
Hautamäki, J., Kupiainen. S., & Hautamäki, A. (2008). Conclusion. In J.
Hautamäki et al. (Eds.), PISA 06 FINLAND. Analyses, reflections and explanations
(pp. 213-219). OECD PISA, CEA, University of Helsinki, Ministry of Education:
Publications 2008, 44.
Hesse, E. (1996). Discourse, memory, and the Adult Attachment Interview: A note
with emphasis on the emerging cannot classify category. Infant Mental Health, 17,
4-11.
Hesse, E. (1999). The Adult Attachment Interview. Historical and current
perspectives. In J. Cassidy, & P.R. Shaver (Eds.), Handbook of attachment. Theory,
research, and clinical applications (pp. 395-433). New York, London: The Guilford
Press.
Hesse, E. (2008). The Adult Attachment Interview. Protocol, method of analysis,
and empirical studies. In J. Cassidy, & P.R. Shaver (Eds.), Handbook of attachment.

51
 Theory, research, and clinical applications (pp. 552-598). New York, London: The
Guilford Press.
Ingold, T. (1997). Finland in the New Europe. People, community, and society. EAGLE
Street, Newsletter of the Finnish Institute in London, no.4.
Kalliala, M. (2000). Play in changing society. In A. Hautamäki (Ed.), Emergent
trendes in early childhood education – towards an ecological and psychohistorical analysis
of quality (pp. 123-181). University of Helsinki, Department of Teacher Education,
Research Reports 216.
Keller, H., Yovsi, R., Borke, J., Kärtner, J., Jensen H., & Papligoura, Z. (2004).
Developmental consequences of early parenting experiences: Self organization and
self regulation in three cultural communities. Child Development, 75, 1745-1760.
Kemppinen, K. (2007). Early maternal sensitivity: Continuity and related risk factors.
University of Kuopio, Department of Pediatrics: Kuopio University Publications D.
Medical Sciences 412.
Kwako, L.E., Noll, J.G., Putnam, F.W., & Trickett, P.K. (2010). Childhood sexual
abuse and attachment: An intergenerational perspective. Clinical Child Psychology and
Psychiatry, 15(3), 407-422.
Kouvo, A.M. & Silvén, M. (2010). Finnish mothers’ and fathers’ attachment
representations during the child’s first year predict psychosocial adjustment in
preadolescence. Attachment & Human Development, 12, 529-549.
Landa, S. & Duschinsky, R. (2012). Letters from Ainsworth: Contesting the
`organization´ of attachment. Journal of the Canadian Academy of Child and
Adolescent Psychiatry, 22(2), 172 – 177.
Landa, S. & Duschinsky, R. (2013). Crittenden’s Dynamic-Maturational Model of
Attachment and Adaptation. Review of General Psychology, 17(3), 326-338.
LeDoux, J. (2002). The synaptic self: How our brains become who we are. London:
Macmillan.
Lieberman, A., Padron, E., Van Horn, P., & Harris, W. (2005). Angels in the nursery:
The intergenerational transmission of benevolent parental influences. Infant Mental
Health, 26(6), 504-520.
Lippe, A. von der, & Crittenden, P.M. (2000). Patterns of attachment in young
Egyptian children. In P.M. Crittenden, & A.H. Claussen (Eds.), The organization of
attachment relationships. Maturation, culture and context (pp. 97-114). Cambridge:
Cambridge University Press.
Main, M. (1977). Analysis of a peculiar form of renunion behaviour seen in some
day-care children. In R. Webb (Ed.), Social development in childhood (pp. 33-78).
Baltimore, MD: John Hopkins University Press.

52
Main, M. (1979). The `ultimate´ causation of some infant attachment phenomena.
Brain and Behavioural Sciences, 2, 640-643.
Main, M. (1981). Avoidance in the service of attachment: A working paper. In K.
Immelman, G. Barlow, M. Main, & L. Petrinovich (Eds.), Behavioral development:
The Bielefeld Interdisciplinary Project (pp. 651-693). New York: Cambridge University
Press.
Main, M. (1990). Cross-cultural studies of attachment organization. Human
Development, 33, 48-61.
Main, M., & Goldwyn, R. (in press). Adult attachment scoring and classification
systems. University of California at Berkeley: Unpublished manuscript.
Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood and
adulthood: A move to the level of representation. In I. Bretherton, I., & E. Waters
(Eds.), Growing points of attachment. Theory and research. Monographs of the Society for
Research in Child Development 50(1-2, Serial No. 209), 66-104.
Main, M., & Hesse, E. (1990). Parents’unresolved traumatic experiences are related
to infant disorganized attachment status: Is frightened and/or frightening parental
behavior the linking mechanism? In M.T. Greenberg, D. Cicchetti, & E.M.
Cummings (Eds.), Attachment in the preschool years. Theory, research, and intervention
(pp. 161-182). Chicago: University of Chicago Press.
Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/
disoriented during the Ainsworth Strange Situation. In M.T. Greenberg, D.
Cicchetti, & E.M. Cummings (Eds.), Attachment during the preschool years. Theory,
research, and intervention (pp. 121-160). Chicago: University of Chicago Press.
Moilanen, I., Kunelius, A., Tirkkonen, T., & Crittenden, P.M. (2000). Attachment
in Finnish twins. In P.M. Crittenden, & A.H. Claussen (Eds.), The organization of
attachment relationships. Maturation, culture and context (pp. 125-140). Cambridge:
Cambridge University Press.
Nauha, S., & Silvén, M, (2000). Puolisoiden varhaiset kiintymyssuhteet: Viehättääkö
samanlaisuus? Psykologia, 1, 71-81.
Pleshkova. N.L., & Muhamedrahimov, R.J. (2010). Quality of attachment in St
Petersburg (Russian Federation): A sample of family-reared infants. Clinical Child
Psychology and Psychiatry, 15(3), 355-362.
Radke-Yarrow, M. (1998). Children of depressed mothers. From early childhood to
maturity. Cambridge: Cambridge University Press.
Radke-Yarrow, M., Cummings, E.M., Kuczynski, L., & Chapman, M. (1985).
Patterns of attachment in two- and three-year-olds in normal families and families
with parental depression. Child Development, 56, 884-893.

53
 Rauh, H., Ziegenhain, U., Müller, B., & Wijnroks, L. (2000). Stability and change
in infant-mother attachment in the second year of life: Relations to parenting quality
and varying degrees of day-care experience. In P.M. Crittenden, & A.H. Claussen
(Eds.), The organization of attachment relationships. Maturation, culture and context
(pp. 251-276). Cambridge: Cambridge University Press.
Rutter, M., Kreppner, J., & Sonuga-Barke, E. (2009). Emanuel Miller Lecture:
Attachment insecurity, disinhibited attachment, and attachment disorders: Where do
research findings leave the concepts? Journal of Child Psychology and Psychiatry, 50,
529-543.
Schore, A.N. (1994). Affect regulation and the origin of the self. The neurobiology of
emotional development. Hillsdale, New Jersey: Lawrence Erlbaum.
Shah, P.E., Fonagy, P., & Strathearn, L. (2010). Is attachment transmitted across
generations? The plot thickens. Clinical Child Psychology and Psychiatry, 15(3), 329-
346.
Simpson, J.A. & Belsky, J. (2008). Attachment theory within a modern evolutionary
framework. In J. Cassidy, & P.R. Shaver (Eds.), Handbook of attachment: Theory,
research, and clinical applications (pp. 131-157). New York, London: The Guilford
Press.
Spieker, S., & Crittenden, P.M. (2010). Comparing two attachment classification
methods applied to preschool strange situations. Clinical Child Psychology and
Psychiatry, 15(1), 97-120.
Sroufe, L.A., Egeland, B., Carlson, E.A., & Collins, W.A. (2005).The development of
the person. The Minnesota study of risk and adaptation from birth to adulthood. New
York, London: Guilford.
Strathearn, L., Iyengar, U., Fonagy, P., & Kim, S. (2012). Maternal oxytocin response
during mother-infant interaction: Associations with adult temperament. Hormons
and Behavior, 61, 429-435.
Thompson, R.A., Lamb, M., & Estes, D. (1982). Stability of infant-mother
attachment and its relationship to changing life circumstances in an unselected
middle-class sample. Child Development, 53, 144-148.
Thompson, R. A., & Raikes, H. A. (2003). Toward the next quarter-century:
Conceptual and methodological challenges for attachment theory. Development and
Psychopathology, 15, 691-718.
Tronick, E.Z. (1989) Emotions and emotional communication in infants. American
Psychologist, 44, 112-119.
Tronick, E.Z. (2008). Emotions and emotional communications in infants. In J.
Raphael-Leff (Ed.), Parent-infant psychodynamics. Wild things, mirrors & ghosts (pp.
35-53). London: Anna Freud Centre.

54
van IJzendoorn, M.H. (1995a). Adult attachment representations, parental
responsiveness, and infant attachment: A meta-analysis of the predictive validity of
the Adult Attachment Interview. Psychological Bulletin, 117, 387-403.
van IJzendoorn, M.H. (1995b). Of the way we were: On temperament, attachment,
and the transmission gap: A rejoinder to Fox. Psychological Bulletin, 117, 411-415.
van IJzendoorn, M.H., & Bakermans-Kranenburg, M.J. (2008). The distribution
of adult attachment representations in clinical groups: A meta-analytic search for
patterns of attachment in 105 AAI-studies. In H. Steele, & M. Steele (Eds.), Clinical
applications of the Adult Attachment Interview (pp. 69-96). New York: Guilford Press.
van IJzendoorn, M.H., & Sagi-Schwartz, A. (2008). Cross-cultural patterns of
attachment. Universal and contextual dimensions. In J. Cassidy, & P.R. Shaver (Eds.),
Handbook of attachment: Theory, research, and clinical applications (pp. 880-905). New
York, London: The Guilford Press.
van IJzendoorn, M.H., Schuengel, C., & Bakermans-Kranenburg, M. (1999).
Disorganized attachment in early childhood: Meta-analysis of precursors,
concomitants, and sequelae. Development & Psychopathology, 11, 225-250.
Vondra., J. I., Hommerding, K.D., & Shaw, D.S. (1999). Stability and change in
infant attachment in a low-income sample. In J.I. Vondra, & D. Barnett (Eds.),
Atypical attachment in infancy and early childhood among children at developmental risk.
Monographs of the Society for Research in Child Development (pp. 119-144). Oxford:
Blackwell Publishers.
Vondra, J.I., Shaw, D.S., Swearingen, L., Cohen, M., & Owens, E.B. (2001).
Attachment stability and emotional and behavioral regulation from infancy to
preschool age. Development and Psychopathology, 13, 13-33.
Waters, E., Hamilton, C.E., & Weinfield, N.S. ( 2000). The stability of attachment
security from infancy to adolescence and early adulthood: General introduction.
Child Development, 71, 678-683.
Weinfield, N.S., Sroufe, L.A., & Egeland, B. (2000). Attachment from infancy
to young adulthood in a high risk sample: Continuity, discontinuity, and their
correlates. Child Development, 71, 695-702.
Weinfield, N.S., Sroufe, L.A., Egeland,B., & Carlson, E. (2008). Individual
differences in infant-caregiver attachment – conceptual and empirical aspects of
security. In J. Cassidy, & P.R. Shaver (Eds.), Handbook of attachment. Theory, research,
and clinical applications (pp. 78-101). New York, London: The Guilford Press.
Winnicott, D.W. (1971/1989). Playing and reality. London: Tavistock/Routledge.
(Original work published 1971).

55
 Zanetti, C.A., Powell, B., Cooper, G., & Hoffman, K. (2011). The circle of security
intervention: Using the therapeutic relationship to ameliorate attachment security in
disorganized dyads. In J.Solomon, & C. George (Eds.), Disorganized attachment and
caregiving (pp. 318 – 342). NewYork: Guilford Press.
Zuckerman, B., & Zuckerman, P. (2005). The pediatrician as a ghostbuster: Angels’
voices and kisses. Infant Mental Health, 26(6), 529-532.

56
Treatment of family
interaction and attachment
relationships: Clinical
interventions based on the
Dynamic-Maturational Model
(DMM)

Bente Nilsen, Clinical child psychologist

Ringerike BUP (Child and Adolescent
Mental Health Clinic),
Vestre Viken Health Trust, Norway

Author note. – Thanks Simon R. Wilkinson for substantial help for

improving this manuscript.

57
 Abstract
This paper describes how attachment needs are addressed in a service
for families requiring attention in an outpatient mental health ser-
vice. This includes a specialised unit for infant and toddler families.
In Norway there are more than 40 outpatient mental health clinics
with such special units for infant and toddler families. Parent-child
interaction and attachment assessments provide a valuable basis for
intervention. An attachment informed formulation addressing how
negative affect and discomfort are addressed within the caring rela-
tionships provides the building block for a therapeutic plan. Through
acknowledging and accepting the discomfort and distress of troub-
led dyads our goal is to facilitate their participation in change. Our
service has an additional commitment to present evidence to court
proceedings when interventions fail and infants are at risk for mal-
treatment. By using CARE-Index (0-15 months) and Preschool As-
sessment of Attachment (PAA) (2 - 5 years) our unit tries to address,
how the infant or toddler/care giver dyads solve the interpersonal
dilemmas that can occur when past traumas and losses intrude into
present caregiving. Bowlby’s idea as carried forward into the DMM
(Dynamic-Maturational Model of Attachment and Adaptation), of
attachment as an organisational system for protecting oneself, one’s
partner, and one’s children provides a basis for understanding the
role of danger in eliciting psychological and behavioural organisa-
tion. This can include behaviour, which at first sight might seem
maladaptive in the context of our assessments. These phenomena is
brought into therapy by exploring past and present dangers parents
have experienced and that can create havoc by popping up unan-
nounced, as it were, within their attachment relationship with their
infant or toddler.

Corresponding author Bente Nilsen, BUP, Ringerike, Vestre Viken

Health Trust, Norway, Nilsen.bente@gmail.com

58
Attachment based treatment
The concept of attachment is on everyone’s lips in services to infant
and toddler families in Norway. Much attention though is directed
toward facilitating secure attachment through dyad-focused therapy.
This paper describes how understanding the function of anxious at-
tachment is essential to help relationships remain safer under threa-
tening and adverse conditions and serves to direct therapeutic pro-
cesses in infant and toddler families. A challenge for relational based
interventions is how to formulate goals coherent with a functional
understanding of how these relationships are organised according to
contingencies under which they live. This paper describes therapeu-
tic work at a Unit for infants and toddlers in a mental health clinic
(BUP Ringerike) in a small town northwest of Oslo.
The DMM – a model suited to risk populations. The Dynamic-
Maturational Model of Attachment and Adaptation (DMM) (Crit-
tenden, 2008) has over the past 20 years been introduced to various
professionals in Scandinavia, Europe, North- and South America and
Australia/New Zealand. This model is particularly suited to identify-
ing individual, dyadic and family differences in understanding how
risk populations organise themselves strategically for self-protection
(Fonagy, 2013). The DMM offers a comprehensive framework for
understanding the conscious and non-conscious processes that affect
how parents’ intentions of ensuring safety may lead to threatening
or dangerous experiences for children. Central to the DMM is un-
derstanding the role of danger in eliciting psychological and behav-
ioural organisation as shown in self-protective attachment strategies.
Nevertheless these may seem maladapted to the current situation in
which the child finds itself. Our services understand the anxious at-
tachment strategy as an individual’s attempt to solve the problems or
dangers (physical or psychological, conscious or non-conscious) that
he or she faces within the attachment relationship, family, culture or
context. Thus, anxious attachment is not considered a difficulty nec-
essarily to be “solved” or changed, but to be understood and accept-
ed as a solution to a real problem. Our attention should therefore be
directed to how these problems or dangers influence organisation of

59
 behaviour within families who pose a risk to their children’s develop-
ment. A comprehensive understanding of risk factors should include
historical, cultural, contextual and psychological threats as a base for
forming functional case formulations and treatment plans. For indi-
viduals, this understanding of human adaptation changes the focus
from the individual’s lack of competence in handling adverse experi-
ences to an understanding of how such experience calls for solutions,
which may prove adaptive or maladaptive in other contexts. DMM
thus conveys an attitude of “mastering developmental conditions”.
At the Unit for Infant and Toddler Families within the Child and
Adolescent Clinic (Ringerike BUP) parent-child interaction is as-
sessed according to DMM informed assessments. DMM provides a
base for understanding relational dilemmas and distress, and influ-
ence how our service is conducted. Norway guarantees parental paid
leave for a year after childbirth (fathers have their own unique time
and can also share part of the parental allowance), and has day care
for all children beginning at one year of age. Compared to the situ-
ation in Europe, Norway is less affected by the economic problems
other nations struggle with. Despite this public wealth, Norway has
serious problems with drug and alcohol abuse, young people drop-
ping out of education, and sustaining a population in the rural, often
remote, areas. In addition, Norway has serious problems handling
immigration in general, and traumatised refugees from dangerous
countries in particular. Refugee families spend long periods of time
in refugee centres without jobs and with an uncertain future regard-
ing being accepted into Norway. These families often feel isolated in
Norway; they are separated from their extended family in caring for
children. Additionally many children in Norway live in families with
domestic violence, parental psychiatric disorders (depression), and
marital problems. These children experience maltreatment. Never-
theless Norway has the political will and awareness to attend to fam-
ily problems, and the financial resources and programmes to address
them. Unfortunately the long-term results of such programmes are
often limited. Mental health issues in Norway are significant, despite
the public wealth, and an unsurpassed allocation of resources to im-
prove mental health.
Infants are mainly admitted to our clinic because of parental men-

60
tal health issues, high levels of conflict within their families or sus-
pected risk for maltreatment. Our unit’s goal is to go beyond the
symptom-based reports of problems and traditional assessments, by
using assessments of parent-child interaction and attachment to gen-
erate functional formulations of the families’ problems. To cite Leo
Tolstoy (1917) from his novel Anna Karenina: “All happy families
resemble one another, each unhappy family is unhappy in its own
way”. It is our aim to understand and make a comprehensive descrip-
tion of how this unhappiness affects the individuals of these families.

DMM-informed assessment
Understanding the family’s attachment strategies is crucial to obtain
information about the problems in each family and begin to plan
for intervention. Application of valid and reliable methods to assess
development, interaction, attachment strategies and overall family
adaptation is crucial to this work. The assessments are particularly
drawn from the life-span set of DMM assessments of attachment
(Farnfield, Hautamäki, Nørbech, & Sahhar, 2010). Specifically, the
CARE-Index (Crittenden, 2005) and Preschool Assessment of At-
tachment (PAA) (Crittenden, 1992) are used with most families and
coded blindly by reliable coders to ensure that the assessment of the
interaction and the attachment relationship is reliable and not biased
by information that can obscure coding.
Using the CARE-Index. The choice of method for assessing the
interaction and the attachment relationship is based on the child’s
age. For small infants, the CARE-Index (0-15 months) is used to
evaluate the quality of adult-infant interaction, to evaluate maternal
sensitivity and infant cooperation in each dyad (Crittenden, 2005).
The CARE-Index involves just three to five minutes of video-record-
ed play interaction and can be carried out anywhere (at home, in a
clinic, etc.).
The CARE-Index provides information about what kind of dis-
tortion there is in the parents’ non-sensitive interaction patterns
(controlling or unresponsive) and how the infant deals with such

61
 distortions (cooperatively, compulsively, with difficult behaviour,
or passively). The CARE-Index assesses interactive behaviour in a
functional way, meaning that 1) any adult behaviour can function
sensitively if it pleases the infant, 2) the same behaviour can mean
different things in different dyads or contexts, 3) meaning is con-
structed within the dyad, and 4) negative affect and intentions are
often disguised and hidden from view. Thus, CARE-Index is a valu-
able method for observing and understanding both conscious and
non-conscious information as processed within a dyad. By using the
CARE-Index, we observe how adult behaviour functions in each
dyad, form a hypothesis regarding what motivates the behaviour or
affect, and gather information regarding points of entry for subse-
quent therapeutic video-feedback with the parents.
The Jonas case. Jonas was admitted to our clinic when he was
2 months old due to birth complications following birth by emer-
gency caesarean section. The emergency precipitated a recurrence
of mother’s previous anxiety and depressive symptoms. In the first
videotaped CARE-Index mother would reluctantly touch or talk to
Jonas, and if she touched him she would look very concerned and
talked to him about her constant worries (“you are not happy, what
can I do”). When she picked up Jonas, she had a painful look on her
face, and as the baby came in close to her she would grimace, as if the
closeness was painful and upsetting to her. Jonas would immediately
respond to this by looking away and start fussing.
The CARE-Index analysis of this interaction suggested a hypoth-
esis regarding mother’s helplessness and reticence to interact with Jo-
nas, thus functioning unresponsively to Jonas subtle and somewhat
passive signals. After picking him up, and when close to mother’s
worried face, Jonas would respond with protest and difficult behav-
iour. His mother presented her worries to the therapist that Jonas
didn’t like her, and that she was unable to soothe him. Mother had
repeated panic attacks when Jonas started crying. It was also clear that
the unpredictable handling of Jonas body would increase his discom-
fort. The treatment plan focused first on how to help both parents
decrease the fussing and crying by predictable soothing and comfort
of the baby. They were also guided to construct some sentences they
could use to say to themselves and the baby: “I understand you are

62
upset. That is ok. I will try to help you”. These sentences were meant
to give meaning to mother in both accepting the discomfort, but
also creating a more optimistic and coping self-instruction for her.
When parents reported a decrease in fussing, therapy could turn to
address the underlying issues regarding mother’s expressed discom-
fort with bodily closeness. In video-feedback mother observed her
own responses to her baby, which in the beginning was quite upset-
ting for her. She was able to acknowledge how disgusted she looked,
as Jonas came close to her face. Her initial response was sadness and
shame. Father became quite anxious regarding mother’s sadness, and
initially psychologically withdrew from her to protect himself. The
therapist used this moment to address mother’s need for comfort
from Jonas’ father, as she felt upset and sad, as much as Jonas needed
his parent’s predictable comfort when he was upset. The treatment
process focused on how this young family organised themselves
around the handling of fear of closeness, and negative affect, such
as sadness and fear. Every time parents came to the therapist there
would be renewed exploration of this theme, with and without new
video material. This case illustrates how acceptance and focus on dis-
comfort within family relationships can lead to a meaningful thera-
peutic process to give better understanding of human needs.
The Preschool Assessment of Attachment. The Preschool Assess-
ment of Attachment (PAA) (Crittenden, 1992) is used when the
child is 2-5 years old. This is a more complex procedure than the
CARE-Index and requires special facilities (a room with a one-way
mirror and a staff of three people). Most parents becomes aware of
how the strange situation procedure, used here, creates dilemmas
and introduces stress to the relationship in order to elicit the child’s
attachment strategy. Compared to the CARE-Index, the PAA gives
a clearer understanding of how the dyad organises their attachment
relationship. Consequently, it provides a more comprehensive base
for hypotheses regarding how the processing of information is man-
aged within the dyad, for example, what is omitted or distorted, and
how distortions affects the dyad. The PAA speeds up the process of
our understanding how the dyad functions and how the child solves
the problems within the parent-child relationship.
The case of Siri. Siri, 2 ½ years old, and her mother were admit-

63
 ted to BUP Ringerike due to on-going conflicts. Mother was herself
in treatment for depression and attended group therapy. In day-
care Siri was described as a quite competent, somewhat stubborn,
and creative little girl. They observed conflicts between mother and
Siri in the mornings and afternoons, and noticed that mother ap-
peared helpless and frustrated. With mother’s consent the therapist
conducted the strange situation procedure (SSP) that was analysed
using the PAA (Crittenden, 1992). The analysis of Siri’s attachment
strategy with her mother showed a coercive (Type C) strategy, where
mother’s helpless and unpredictable behaviour was paired with Siri’s
frequent use of threatening and aggressive displays to coerce mother.
This strategy functioned to attract mother’s attention. When mother
responded with anger, Siri would disarm mother’s aggression by dis-
playing coy and helpless behaviour. After SSP was conducted mother
was very eager to view the videotape because she felt that the conflicts
she tended to have with Siri at home, had also been present during
the procedure. Many parents feel relieved that what they experience
as relationship problems with their young children recur when ob-
served by experts. This is often the case during SSP, especially when
it comes to observation of the coercive attachment strategies. Mother
and therapist set up three treatment sessions to look through the
videotaped PAA. At the first session mother immediately became
aware of how she behaved with Siri. She was amazed by how her be-
haviour appeared helpless, vague and unpredictable. She associated
her displayed behaviour with what had been focused on in group
therapy - how to present herself more distinctly and stick to her own
decisions. In the following sessions mother and therapist reflected on
many aspects of the functional connection between mother’s behav-
iour and Siri’s responses. Mother attributed intention and theory of
mind to Siri’s displays of frustration and anger. By doing so the in-
teractional sequences was maintained. After the first session mother
reported changes she had made in order to manage her parental role
with greater predictability - fewer questions, suggesting solutions and
guiding Siri through activities they both could enjoy. Mother report-
ed how helpful it was to be able to observe and understand how her
own behaviour influenced her child, making herself confident that
she could master the daily challenges of life with her daughter more

64
constructively. She could be more in charge, as opposed to how she
initially had felt coming to our unit. PAA, using SSP produced the
required stress in this dyad in order to elicit Siri’s attachment strategy
with her mother. This made it possible to address their challenges
directly and also correct mother’s understanding of Siri’s intentions.

Managing intervention
How individuals organise themselves self-protectively is closely tied
to the degree of brain maturation at the time when the problem
or danger is faced. For infants and toddlers, whose maturation is
incomplete, that means that threats can be difficult to comprehend,
easily misunderstood and therefore responded to in ways that both
protect the children, but also distorts information regarding future
threats. Meaning is dyadic specific and created within each relation-
ship. For infants and toddlers crucial information is sought from
parents regarding how they feel. What parents perceive as important
to respond to provides information regarding what distortions of
information processing will be necessary to address with parents. In
treatment, such interactional ruptures and distortions are important
to detect because they function as potential windows of opportunity
for repairing the interactional dance. Repairing processes are central
to interactional therapy, as in the case of Jonas and his parents.
For parents, the issue regarding self-protection is tied to their
own past experiences. Whether they were endangered in early child-
hood, and the meaning they attributed to their experience influence
how their distortions of information are carried forward into their
adulthood. Parents may be consciously aware of such past dangers,
but they often try to hide these experiences from themselves, their
family and therapist. In other cases previous dangerous experiences
are not available for conscious awareness. The therapeutic process
needs to address both trajectories of human experience, conscious or
non-conscious, and seek to make them available for mutual explora-
tion. This was the case for Jonas’ mother, and she could gradually
accept the meaning behind her feeling of helplessness and anxiety

65
 with her baby. Understanding and accepting past experiences and
their associated strategic solutions can be paired with the search for
therapeutic goals for the parent-child relationship. The possibility
of understanding their own needs as in tune with the needs of their
own children may open a safer way to the repairing process for par-
ents. Parental strategies of self-protection from their past can become
accessible in therapy and help to understand their continuing need
for self-protection regardless of age. As all humans do.
In both cases, transformation of information represents a non-
conscious short cut in thinking that reduces complexity. Non-con-
scious experiences are important to address because affective trans-
formation of information is important in change processes (Schore,
2012). A way of getting access to these non-conscious processes is by
accessing the implicit transformations of self-relevant information.
Therapy can address the non-conscious affective embodied experi-
ences by using video feedback. Observing the parent-child interac-
tion can help parents access these processes and their functions for
themselves. The transformations of information in both children
and their parents need to be understood in order to deliver a suitable
treatment to each individual in the context of their relationship. As
in the case of Siri, mother was confronted by her own behaviour, and
how she affected Siri. This enabled mother to reflect on connections
between her interactive behaviour with Siri and her own treatment
themes.
Several approaches to working with parents are used by the infant
and toddler unit at our mental health clinic. An aim for intervention
and therapy is to offer parents’ better tools to observe and compre-
hend their own and their infant’s expression of feelings and desires.
By constructing this sort of meta-perspective parents can reflect on
behavioural, affective and somatic expressions in their relationship
with their children. As a result, it is hoped that they will come to
understand the processes in their attachment relationship with their
children better, as Siri’s mother was able to. We avoid teaching par-
ents to do what is right from our perspective, and instead help them
to become aware of their own feelings, affective responses, beliefs
and goals. They become more mindful. This can take place by ena-
bling parents to gather evidence for their own developmental process

66
through picking up the signs of connections between themselves and
their infants, as was the therapeutic goal for both Jonas’ and Siri’s
attachment relationships.
Video-feedback. Video-feedback is a powerful method for engag-
ing parents in reflecting on their own behaviour together with their
infants. This is much harder to do with parents who lack awareness
of the issues that has brought their infant and family to attention,
whether this is from a medical or a child protection perspective. The
crucial thing in use of video is to find an opening where parents can
realise that the children’s needs for feeling cherished and valued are
congruent with their own desires. Using the 3-minute interaction
(CARE-Index) as the basis for feedback, parents are encouraged to
look for moments when they sought a response from the baby as
a confirmation of being good enough. This may, for instance, be
when the baby is touched, kissed or her position is changed. In such
moments, it can be helpful to observe the infants’ responses as the
parent can more clearly recall and relate to his or her own inten-
tion a short time after the video-recorded play. For Jonas’ mother it
was predicted that she needed help to make sure she could comfort
Jonas and reduce his fussing before she was able to make use of the
video feedback. Decisions regarding treatment plans require differ-
ent evaluations in each case.
Using the PAA for video feedback provides a clearer base for iden-
tifying a child’s response to parental departure and reunion. Dur-
ing video-feedback, a parent and therapist can focus on crucial and
misleading moments. The child’s behaviour can indicate blocking of
communication of distress and confusion, distortion of their own
feelings by producing positive facial and vocal expressions when they
actually feel anxious. In the case of Siri negative affective and behav-
ioural displays were exaggerated into a coercive strategy. Video-feed-
back has a clear advantage in that the information to answer ques-
tions concerning how a child feels together with her parent lies in the
video. Parents and therapist can together explore how the child (and
parent) is solving these attachment dilemmas. Siri’s mother was able
to pick up the message from Siri’s attempts to solve their relationship
issues. The important thing for Siri was that mother accepted that
she had to make some changes in order to ensure a more predictable

67
 interaction with her child. Her mother could accept that the prob-
lems in their relationship weren’t within Siri, but an incomplete and
maladaptive solution to their relational behaviour.
Our experience is that, when parents are able to acknowledge
the painful and uncomfortable experiences they have together with
their infants, therapists can work from two ends: 1) using these mo-
ments emphatically to acknowledge the parents’ experiences, how
their intentions of doing good can produce opposite effects, and 2)
working on balancing the experience of shame and helplessness with
the possibility for new mutual experiences with their infants. These
processes focus on accepting negative feelings as meaningful infor-
mation, without dismissing or distorting them. That is, we use our
observations and empathy for the parents to enable them to observe
and empathise with their infants; this is consistent with the approach
in Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl,
& Wilson, 2003).
The therapeutic process. This therapeutic approach is not based
on a treatment protocol but is process orientated. It intends to
work as a creative transaction between the functional case formula-
tion, video feedback and parents’ ability to reflect together with the
therapist. This creative process works as an opportunity for parents
to share negative experience and use their attachment strategies in
dealing with them with the therapist as an “available and reflective
haven”, if not a “safe haven.” In Jonas’ case it was crucial that the
therapist could address his parents’ immediate need for help to calm
their distressed and fussy baby. This first step made the relationship
to the therapist more trusting and his mother was able to explore
how her distress with closeness functioned to produce what she
feared the most: signs from the baby that he didn’t like her. The on-
going evaluation of such a treatment process allows the therapist to
carefully introduce the problems that are assessed from the parents’
relationships with their infant/toddler. Thus therapy is considered
a developmental process of change through increasing awareness of
hidden, past and present threats and dangers within the attachment
relationship. Relationship ruptures can present openings for inter-
actional repair. For some parents, the experience of repairing even

68
small ruptures opens the possibility of reflecting on more significant
problems in their own relational experiences (both as a child and
currently with their partners) and with their infants. When this pro-
cess is opened up in therapy, parents’ awareness of the major conflict
between intention and effect can become the subsequent therapeutic
challenge. Acceptance of discomfort and shame, as present in all hu-
man life, can be an opener to accept discomfort within the parent-
infant relationship as a precursor for change. With this perspective,
therapy is not perceived as becoming safe, sound and happy, but
learning how pain, discomfort and unhappiness are human condi-
tions that organise our attachment strategies. This opens up for more
flexible use of strategies on the future, and is in line with DMM
thinking about attachment strategies having the potential for change
throughout the life cycle (Crittenden, 2008).
When interventions fail. Interventions and therapeutic work can
only be conducted as long as therapists at our unit are confident that
the process isn’t associated with higher risk of maltreatment, worsen-
ing of parental mental health or increased possibility of dangerous
situations arising within the family. These issues need to be taken
into consideration in planning for treatment, and thus repeatedly
evaluated during the treatment process. No treatment can do eve-
rything well, and ensure a good outcome for everyone. When inter-
ventions fail, if children are at risk of maltreatment it is mandatory
to report to the Child Protection Services. In the cases that come
before the family courts, professionals must testify in the court pro-
ceedings with evidence for the assessments that are done and report
on the services offered the families. Such evidence is based on the
multiple methodologies and interventions offered in each case; no
single method stands alone.

Understanding anxious attachment

DMM has conceptualised how lack of protection and comfort has
an organising effect on human adaptation to its ontogenetic niche.
In addition DMM has provided age specific assessment methods

69
 that expand and give specific meaning to what professionals ob-
serve within attachment relationships. What is observed is used to
generate empathy and compassion for parental distress through the
therapist’s acceptance of negative feelings and experiences in close
relationships. When parents learn to observe and acknowledge what
they may think of as unexpected and unacceptable responses from
their children, they can come to reinterpret them as meaningful as
solutions to dilemmas for their children in their relations to them.
This can enable parents to be aware of and committed to correcting
distorted information. Treatment within troubled or endangered
families can use these ideas for understanding the functional rela-
tionship between endangering conditions and the self-protective at-
tachment strategies in the therapy process. More generally, profes-
sionals need to understand how anxious attachment constitutes a
short-term resolution to dilemmas and dangers within attachment
relationships. Also parents need tools to seek evidence for their own
process of change within their attachment relationship with their
infants. We have found the DMM ideas regarding danger, self- and
child-protection, and adaptation helpful to our work with endange-
red families. “Do unto parents as you would have them do unto their
children” (Crittenden, 2008) is a fruitful motto for this work.

70
References
Crittenden, P.M. (1992). Quality of attachment in the preschool years. Development
and Psychopathology, 4, 209-241.
Crittenden, P.M. (2005). Der CARE-Index als Hilfsmittel für Früherkennung,
Intervention und Forschung. Frühforderung interdisziplinar (early interdisciplinary
intervention), Special issue: Bindungsorientierte Ansatze in der Praxis der Frühforderung
24, s. 99-106. (English on www.patcrittenden.com.)
Crittenden, P. M. (2008). Raising parents: Attachment, parenting, and child safety.
Cullompton UK: Routledge/Willan.
Farnfield, S., Hautamäki, A., Nørbech, P., & Sahhar, N. (2010). DMM assessments
of attachment and adaptation: Procedures, validity and utility. Clinical Child
Psychology and Psychiatry, 15(3), 313-328.
Fonagy, P. (2013). Commentary on “Letters from Ainsworth: Contesting the
‘organization’ of attachment”. Journal of the Canadian Academy of Child and
Adolescent Psychiatry, 22, 178-179.
Hayes, S.C., Strosahl K.D., & Wilson, K.G. (2003). Acceptance and Commitment
Therapy. An experiential approach to behavior change. New York: The Guilford Press.
Schore, A.N. (2012). The science of the art of psychotherapy. New York: Norton.
Tolstoy, Leo (1877). Anna Karenina. The Russian Messenger (Serial).

71
 Chapter 3: Psychotherapists’
and patients’ dispositional
representations of danger:
Intervention planning using
DMM assessments

Andrea Landini, M.D., child and

adolescent psychiatrist
Family Relations Institute, Miami,
USA - Reggio Emilia, Italy

Abstract
This paper is about how psychotherapists represent their understan-
ding of the clinical situations they assess and treat. Psychotherapists’
professional dispositional representations are analysed from the
point of view of universal human information processes based on
mental dispositional representations.
Human protective action is based on a multiplicity of mental
representations of danger and safety. In the Dynamic-Maturational
Model of Attachment and Adaptation (DMM; Crittenden, 2000,
2008) these representations are labeled “dispositional representa-
tions” (DR; Crittenden, Dallos, Landini, Kozlowska, in press). DRs
are parallel neural pathways, activated by sensory stimulation. Each
parallel pathway disposes to self-protective action, and is based on
an attribution of meaning to sensory stimulation. The meaning is at-
tributed by combining aspects of the external context with aspects of

72
the self; the combination is reflected in the activated neural pathway.
As long as the activation lasts, it is an active DR of the relationship
between self and context in that moment. Each active DR changes
the probability of a similar pattern of activation (that is, a similar
DR) occurring in the future in response to similar sensory stimula-
tion.
Each DR disposes the individual to take some protective action,
but not all of these actions are compatible with each other, e.g.,
capable of producing the same result, or maximally attuned to the
current dangers. To act in a protective way, the individual needs to
choose which DR or set of DRs can function coherently to motivate
adaptive protective behavior. Self-protective strategies are conceptu-
alized by the DMM as learned ways of using one’s mind to sort out
from multiple dispositional representations the one that will organ-
ize behavior. Unlike the psychological process, the outcome is visible
behaviorally as strategically coherent protective action, chosen to be
maximally protective in the most economical way.
What is theorized by the DMM for humans in general should be
valid also when therapists try to protect patients who turn to them
seeking relief from feeling anxious, depressed, confused, or physical-
ly ill. This chapter describes in formal terms some processes used by
therapists (sometimes without full awareness) to construct their own
professional dispositional representations (PDR) of each patient’s
condition. PDRs function just like any other DR to dispose to pro-
tective action. They guide therapeutic choices. Three types of PDRs
will be discussed in terms of how they are derived and how they
function: 1) descriptive diagnoses, 2) functional diagnoses, 3) family
functional formulations. Finally, strategies for integration of these
representations, leading to therapeutic action, will be considered.

Corresponding author Andrea Landini, Family Relations Institute,

Miami, USA – Reggio Emilia, Italy, dutil@tin.it

73
 Descriptive diagnoses: Detecting
potentially meaningful behavior
The descriptive symptom-based diagnoses collected in diagnostic-
statistical manuals like DSM and ICD are PDRs. They can be con-
ceptualized as semantic summations made by a therapist of: 1) epi-
sodes or scripts about behavior noticed by a patient or observers of
a patient (family, school, work) or elicited by the therapist’s questio-
ning; 2) verbal accounts of subjective experiences by patients. The
semantic summations are to be chosen within the diagnostic-statistic
manuals: the complexity of observations and accounts is therefore
summarized in a generalized label. Interestingly, although a descrip-
tive diagnosis draws on a number of sources of information, the final
form of this PDR does not clearly specify if the sources of infor-
mation are in agreement or if there are differences, and what they
are. This focuses clinical attention on the behavior of the patient,
trying to reach maximum precision on its “best” description. The se-
mantic, generalized form of the descriptive diagnoses also omits the
conditions that elicit an individual’s symptomatic behaviors or expe-
riences. The summation of the descriptive label states that symptoms
characterize an individual, but does not specify where or when these
occur. Most crucially, it leaves out of its focus the interpersonal con-
ditions that are associated with symptoms.
When a descriptive diagnosis is formulated, the therapist knows
something therapeutic is to be done. As this type of PDR is symptom-
based, it tends to dispose to symptom-relieving actions (although it
is not always clear whose relief is sought, due to the source issues
discussed above). Despite generally not leading reliably to the treat-
ment of the causes of mental disorders, the descriptive diagnoses are
currently the ones that look most professional to the general public.
They are collected in acronym-named books, ordered in systematic
ways, and widely quoted in the literature, both scientific and general
(with increasing precision).

74
Comparison of descriptive diagnoses in general
medicine and mental health
Descriptive symptom-based diagnoses of mental disorders are deri-
ved from the general medical template of collecting physical symp-
toms and signs into syndromes (such as a grouping of nausea, vomit,
abdominal pain in the lower right quadrant and abdominal muscu-
lar rigidity is a collection of symptoms compatible with a diagnosis
of appendicitis). A recurrent physical syndrome, researched in terms
of causes and processes, can be recognized as a meaningful pattern;
when diagnosed, such a syndrome has implications in terms of prog-
nosis and treatment. The previous syndrome means surgery is an op-
tion; if fever is added to the syndrome, the prognosis can be worse.
The collection of physical syndromes in diagnostic manuals has been
useful in optimizing the economical use of resources in treatment: if
a physical syndrome indicates a well understood disease, treatments
that stray from the tried and tested responses require testing before
being applied. With the progress of research in the biology of physio-
logical and pathological processes, biochemical testing and imaging
have become crucial in refining diagnoses of physical diseases.
On the other hand, our current shared professional understand-
ing of mental disorders is not easily comparable to this paradigm:
signs and symptoms are mainly behavioral (only seldom somatic),
often transient, context-dependent, and on a continuum with nor-
mal behavior with fuzzy cut-offs. Most important, our understand-
ing of the causes of mental disorders is often only theoretical (and
controversial), and the relevant processes are usually conceptualized
in abstract terms and often contested by therapists using different
theories. In particular, the relation between symptom and disorder
is highly contested. Therefore, the connections between syndromes
and treatments are usually quite thin, with most of the knowledge
being about symptom reduction. Professionals may even disagree on
whether the treatment really addresses the disorder or only the vis-
ible evidence of the disorder.
In the meantime, the widespread use of the descriptive diagnos-
tic categories has reified these ”names” into ”things”, to the point

75
 that even scientists lose track of their nature. In May 2013, Thomas
Insel, the director of USA National Institute of Mental Health said
to the New York Times (Belluck & Carey, 2013) that ”his goal was
to reshape the direction of psychiatric research to focus on biology,
genetics and neuroscience so that scientists can define disorders by
their causes, rather than their symptoms”. Another quote was: “As
long as the research community takes the DSM to be a bible, we’ll
never make progress”. Still, despite the risk of slipping into dogma,
descriptive diagnoses are widely used. They retain functions that are
of basic import.

The functions of descriptive diagnoses of

psychiatric disorders
Descriptive diagnoses collect “signifier behaviors” across various
functional domains that involve marked anomaly or impairment
of normal functioning and behavior. As such, they are the reper-
toire of how distress appears in forms that are socially recognized as
signaling the need of intervention. In fact, descriptive diagnoses of
mental disorders by qualified professionals are the process for ob-
taining social and economic benefits, services, and exemptions. The
syndromes have come to represent a social process by which families
or individuals who can no longer adapt to their current conditions
are acknowledged as needing help from extra-familial systems. The
whole category of descriptive diagnoses can be seen as carrying this
overarching social meaning.
Many of the criteria for descriptive diagnoses actually call for a
multi-source assessment that, because of practical constraints, is
rarely carried out thoroughly. There are several reasons for this. The
symptomatic individuals are quite likely to use distorted mental
information processing. Consequently, as sources about their own
experience, they are both invaluable and skewed. Their families can
add bias-reducing or complementary perspectives, but they have
been shown to be in substantial disagreement with external trained
observers (Achenbach et al., 1987). People from external contexts
(for example, schools, work, and social environments) would be the

76
obvious source for information about social adaptation and overall
impact of symptoms, but their observations are unlikely to be very
detailed. The therapist would have to take into account each source’s
likely biases, fitting the information in an overall picture. How likely
is it that the average therapist is able to access this array of sources
about personal functioning in a context relevant, for example, to
drug prescription? The final form of a descriptive diagnosis, in fact,
does not record its sources of information: there is no way to assess
source validity of a descriptive diagnosis without “unpacking” the
process that led to its selection by the therapist. It might well be that
a descriptive diagnosis looks objective mainly because of its semantic
format (that is, generalized, impersonal, representing predictability).

Descriptive diagnoses from a DMM perspective

A descriptive diagnosis, in a DMM-informed treatment, is best con-
sidered a starting point that warrants: 1) the beginning of an in-
tervention and 2) further understanding through careful assessment
before the diagnosis can lead to a proper treatment plan. Questions
that might help to put a descriptive diagnosis into perspective are:
how representative is this specific descriptive diagnosis of the signi-
ficant behaviors? Does the array of symptoms suggest other alterna-
tive or co-morbid diagnoses? Are all relevant sources of information
represented in the diagnosis? Are there other behaviors that are re-
levant? In which conditions do the symptomatic behaviors appear?
Because accurate behavioral description is the only possible basis
for useful functional interpretations of symptomatic behaviors, the
limits of the descriptive diagnoses are not in the fact that they are
descriptive: if anything, they are not descriptive enough for the pur-
pose of guiding intervention. Being semantically summative, they
cannot provide detail about symptoms in context, and therefore do
not address at all the possible functions of symptom behavior (adap-
tive or maladaptive). They are therefore unlikely to dispose therapeu-
tic actions that affect causes of mental disorders.

77
 Functional diagnoses: Recognizing
protective strategies through DMM
assessments
When a descriptive diagnosis has been defined, a therapist knows
that something is to be done. But what, exactly? To address this
question, another type of professional dispositional representation
is needed: a functional diagnosis. This type of PDR is an integra-
tive representation based on: 1) a semantic definition of a problem
(either a descriptive diagnosis by a therapist, or non-professional de-
finitions provided by the patient’s family or entourage); 2) episodic
descriptions of the patient’s general lifestyle and adaptation (from a
variety of sources); 3) samples of behavior that are representative of
the patient’s symptoms and of their daily functioning (recorded in
various ways, and therefore varying from procedural, to imaged, se-
mantic, connotative, episodic or integrative information); 4) further
information about the context for the sampled behaviors both in
terms of antecedents and outcomes of the behaviors (temporal se-
quences in which the samples of behavior are embedded) and in
terms of simultaneous conditions and actions (the set of circums-
tances that is concurrent to the samples of behavior). The functio-
nal diagnosis PDR has the form of an integrative account of how
patients’ behaviors function contextually, in particular, the ability to
adapt to various contexts, and contains an understanding of the fun-
ctions of behaviors from the patients’ perspective. The validity of the
judgment may be higher if the functional diagnosis PDR integrates
information from many different memory systems: this increases the
probability that all critical information about danger as reflected in
an individual’s behavior is included.
A functional diagnosis, therefore, taps the general functioning of
individuals in their life, according to their developmental stage, in
particular, how the symptom behaviors currently function. How is
the individual coping with developmental tasks, in particular, with
personally defined goals? How do symptom behaviors fit in this pic-
ture? This kind of PDR allows the therapist to put the impact of the

78
descriptively diagnosed “mental disorder” in functional perspective,
and to specify goals and processes for treatment.
There have been many attempts to give functional meaning to
symptomatic behavior. Essentially all theories of treatment attempt
to bridge the gap between descriptions of syndromes and therapeu-
tic actions by conceptualizing, analyzing and explaining the pre-
sumed functional processes underlying behavior. Not all theories of
treatment, however, have operationalized methods to find reliable
evidence for the theorized processes. A specified process for moving
from symptoms to functions is needed before alternative functional
explanations can be compared.

DMM assessments: Observing behavior with a

focus on protection from danger
Sensory information is processed mentally by humans to make mea-
ning of circumstances. Mental representations of experience allow
humans to behave in ways that are compatible with survival. Per-
ceiving danger in one’s circumstances guides protective action. The
observation of how humans behave in circumstances perceived as
dangerous, organized by Bowlby’s construct of attachment, led to
the idea of attachment strategies. The recursive coherence found by
observers in protective behavior has allowed recognizing patterns of
behavior that appear to serve an overall strategy. The way danger is
represented mentally, leading to protective action is considered stra-
tegic. This body of observations, interpreted by attachment theory
and extended by the DMM to endangered populations, has focused
on how information processing motivates protective behavior. At-
tachment strategies are theoretical constructs that organize the ob-
served ways in which humans select the most appropriate DRs to
dispose protective behavior. An attachment strategy, in other words,
reflects the habitual neurological processes by which a person diffe-
rentiates what is dangerous from what it safe, and which protective
behaviors are likely to be useful. These processes have been shaped
by experiences of danger and safety and their results for the person.
Some of these processes will be implicit, non-verbal and non-cons-

79
 cious; others will be explicit, conscious and verbal. Strategic functio-
ning is a learned organization of neural functioning that makes sense
of current sensory input on the basis of previous experience, thus
selecting the behaviors that are strategically considered most likely
to be protective. You look at your present trying to predict your
future through the lenses of your past. The biological imperative of
survival seems a likely priority in the organization of human beha-
vior. The notion of protection from danger and reproduction as basic
motivations for human behavior is considered central by the DMM
and used to shape processes of functional interpretations of behavior
(Crittenden, 2000, 2008).

Psychopathology as formerly adaptive strategic

organizations
Attempts at protection which are used beyond their developmental
origin can become inadequate and cause maladaptation. The DMM
would propose this as the basic definition of psychopathology. In
this perspective, all psychopathological behavior is considered to be
motivated by DRs of danger based on transformations of the sensory
input that omit, distort, falsify, deny or delusionally generate infor-
mation. These transformations are meant to quickly extract from
sensory inputs those meanings that, according to previous expe-
rience, dispose most quickly and efficiently to behave protectively.
These patterns of neural transformation of information are con-
ceptualized by the DMM as attachment strategies (Type A and C
strategies use the most sophisticated and extreme transformations of
information; Type B strategies involve very little or no transforma-
tion of information). In the case of psychopathology, the strategic
transformations of information may have been helpful at an earlier
time – indeed so helpful that they became habitual – but are not
well attuned to current circumstances. This lack of fit is substantial
enough to turn the intended protective function of behavior into
various degrees of harm to self or others, sometimes without any
current beneficial function for self and progeny.
Strategic organizations, which appear counter-productive in the

80
present context, can be understood in the context of the history of
past dangers. Individuals that were endangered early on in their his-
tory, unprotected and uncomforted by attachment figures, learn to
use protective strategies that worked so well with great danger that
they are subsequently kept closed to updating or correction. These
currently inflexible strategies, which were crucial for past survival,
tend to remain rigidly and precisely protective for past danger, but
may not be able to acknowledge changes in the self, in the environ-
ment and in currently relevant dangers.

Extreme and modified attachment strategies as

functional evidence of maladaptation
Symptomatic individuals, showing maladaptive behavior or subjecti-
vely experiencing emotional and intellectual distress, are not fitting
well with their current environment. In DMM terms, the strategy
they are using is not up to date with their current stage of develop-
ment and their present context. If a protective strategy is used in a way
that fits the current situation, there should be no psychopathological
symptom: protective actions are adaptive and mental representations
are sufficiently attuned to current dangers. If a person’s behavior shows
evidence of distress, maladaptation, or even warrants a descriptive di-
agnosis of mental disorder, the lack of fit between person and context
can be conceptualized and operationalized in various ways.

The DMM predictions on the matter would be the following:

1) The symptomatic person is expected to use a non-normative
attachment strategy that involves some substantial
transformation of information (namely, A3-8, C3-8 or A3-8/
C3-8 combinations), which represents the learned adaptation to
past unprotected/uncomforted dangers.
2) The non-normative strategy is expected to be observed in
a modified form. This could be a general modification of
the attachment strategy (namely, depression, disorientation,
intrusions of forbidden negative affects, or expression of somatic
signs) or a lack of resolution of one or more past dangerous events.

81
 This hypothesis has been supported by several validation studies for
the DMM assessments (Crittenden et al., 2010; Kwako et al., 2010;
Heller, 2010; Hughes et al., 2000; Ringer & Crittenden, 2007;
Zachrisson & Kulbotten, 2008).

DMM assessments: observing behavioral evidence

of maladaptive protective strategies
The DMM assessments provide a systematic way to carry out be-
havioral functional observations. All DMM attachment assessments
involve circumstances that activate dispositional representations of
danger in the observed individual. This is based on the template of
the Ainsworth Strange Situation (Ainsworth et al., 1978), a procedu-
re designed to elicit strategically organized protective behavior, gene-
rating moderate stress in a child (if stress is too low, there is no need
for protective behavior; if stress is too high, self-protective behavior
is stereotyped and reflects less individual variation). Increasing stress
allows the gradual unfolding of behaviors showing the individual’s
attachment strategy to the attachment figure that is present.
In individuals older than 6 years, the behavior observed can be
verbal, and the attachment strategy is an increasingly more general-
ized form of self- and progeny-protective strategy. Assessments like
the School-Age Assessment of Attachment (SAA; Crittenden, 1997-
2005), the Transition to Adulthood Attachment Interview (TAAI;
Crittenden, 2005) or the DMM version of the Adult Attachment
Interview (DMM-AAI; Crittenden & Landini, 2011) all assume
that, in the context of a conversation about danger with a relatively
unknown person, a speaker would construct their language based on
their learned basic strategy for dealing with information about dan-
ger. The conversations are structured so that the interviewer doesn’t
suggest or evaluate any protective stance, but asks follow up ques-
tions about the speakers’ content in order to clarify the strategic pat-
terning of the speakers’ language. The speech is recorded and tran-
scribed verbatim, and analyzed for evidence of how various types of
information are dealt with strategically. The best way to be sure that
the analysis is only informed by the behavior, and not by extraneous

82
sources of information, is to code “blindly”, that is to have the analy-
sis performed by a coder who has had no previous contact with the
individual, and doesn’t know anything about the reasons for the as-
sessment being administered. Interestingly, the functional diagnosis
as performed by using DMM assessment can be a separate and, for
a while, independent pathway of representing information about a
clinical case, while descriptive diagnoses are being defined elsewhere.
The excitement (and the integrative PDR that is a full functional
diagnosis) will come when the two strands come together for the
integration of information.
The functional analysis of this sample of verbal behavior regard-
ing danger involves addressing various DRs as empirically studied
by cognitive psychology and other disciplines. Namely, procedural
memory and semantic memory are ways to process information
about the temporal order of sensory stimulation, which is used to
infer causal connections in repeated sequences of events. This type
of information, labeled “cognitive” in the DMM, is given priority
in strategic functioning of the A attachment type. In turn, imaged
memory and connotative language are used to process information
about the intensity of sensory stimulation, which, via affective rep-
resentations, allows for judgment about the probability of danger or
safety in various perceptual environments. This type of information,
labeled “affective” in the DMM, is given priority in strategic func-
tioning of the C attachment type.
The integration of cognitive and affective information, triggered
by specific cues (usually the recognition of some form of discrepancy
if spontaneously occurring, or an external request), can be observed
in how speakers tell autobiographical episodes (which require both
sequential and perceptual information to tell a complete story), but
also in how they understand problems, ways to deal with problems,
overall histories of relationships and their own general functioning.
Strategies that involve more extreme transformations of information
will involve episodes told in strategically informed ways, and either
avoidance of integrative reflection, or strong strategic biases in favor
of specific perspectives or goals while attempting an understanding
of problems and circumstances.
Thus a DMM assessment provides a classification of the person’s

83
 basic strategic behavior; this reflects the history of danger for the in-
dividual, as the protective strategy is thought to represent the learn-
ing of the individual about danger both in terms of specific informa-
tion and in terms of mental processing of information about danger
that has proven most efficient.

Attachment strategies as functional PDRs:

working on the basic strategy
This memory-systems-based way of deriving an attachment strategy
classification from a DMM assessment has strong implications for
treatment plans. To stay protective, information processing and be-
havior need to include ways to monitor the current context and get
information on the nature of current dangers. To accomplish this,
a mature enough individual needs to recognize the context-based
function of the more extreme transformations of information, and
assign those transformations to the contexts that warrant them, al-
lowing less transformed dispositional representations to motivate be-
havior in other contexts. In other words, one needs to recognize that
one’s strategy was appropriate to past dangers (or to one’s own past
vulnerability tied to immaturity), and it is now time to update it to a
strategy that takes into account the present vulnerabilities, resources
and dangers. In a most schematic way, then, ideally an intervention
should aim towards the most balanced way of processing informa-
tion, involving metacognitive functioning, which would allow the
most thorough forms of integrative functioning. In other words, the
ultimate, most advanced goal of intervention might be conceptuali-
zed as bringing the strategic functioning of an individual as close as
possible to a B attachment strategy. In this general direction, many
cognitive-based, affect-based or reflective psychotherapeutic techni-
ques can be drawn from the immense repertoire of published treat-
ments, and be conceptualized as modifying specific memory systems
in specifiable ways. Empirical testing of clearly defined therapeutic
actions could then refine the understanding of which techniques are
best employed in which conditions.
But which of the transformations of information highlighted by

84
DMM assessments are currently “dead wood” and which instead
perform protective functions that are strategically well attuned to
the environment and therefore still crucial? DMM assessments, by
providing information about modifiers of the basic strategy or about
unresolved dangerous events, give useful information for this dis-
tinction.

Attachment strategies as functional PDRs:

working on unresolved past dangers
Some information about specific past dangerous experiences might
not be assimilated in the basic protective strategies. If representations
about unprotected and uncomforted experiences remain as unresol-
ved “lumps” of information, therapists can observe in the current
behavior of the individual protective behavior that seems not mo-
tivated by present danger, or conversely the absence of needed pro-
tective behavior. In both cases, current strategic fit to context can
be impaired. This kind of behavior, when observed in DMM assess-
ments, is considered evidence of unresolved traumas or losses, which
can interfere with an integrated protective functioning in a variety
of forms. The interference can be contained, that is restricted to a
relatively small set of circumstances or signals, and have a limited
(albeit significant) impact on the overall functioning of the indivi-
dual. But uncontained forms can also be observed, where the asso-
ciations between current sensory stimulation and the unresolved loss
or trauma are frequent enough to permeate everyday functioning
to pervasive levels. Another form of variation regards the type of
strategic attempts at transformation of traumatic information. The
consequent errors of attribution of relevance to information about
current conditions can range from the mildly distorting to the extre-
mely confusing. Trauma-affected behavior can therefore range from
the mildly maladaptive to the extremely endangering.
The therapeutic implications of finding unresolved losses or trau-
mas in a DMM assessment include the opportunity of addressing
such specific responses to specified past dangers limiting their impact
on present functioning. Again, many techniques exist that can limit

85
 the motivating strength of representations, or can lead to discovery
of appropriate associations, activating new dispositional representa-
tions. It seems important that, when an unresolved trauma or loss
is found, the techniques are aimed with enough precision to inform
about the unresolved events.

Attachment strategies as functional PDRs:

working on modifiers of basic strategies
Another type of poor adaptation of a person to his s current circum-
stances occurs when there is a chronic lack of fit of basic strategy to
the life context. The implicit or explicit recognition of this lack of
fit by the individual is shown in modifications of the ways the stra-
tegy is implemented in behavior. This can be observed in a DMM
assessment as a modified state of the basic attachment strategy. Of
the behavioral features, one is particularly interesting in terms of
its relevance to treatment: the level of arousal tends not to show
normative fluctuations according to changes of conditions in the
self and in the environment. Instead, arousal can be persistently low
(in strategies modified by “depression”), or high (if the modifier is
“disorientation”), or show sudden and surprising swings (with the
modifiers “intrusion of forbidden negative affect” and “expression of
somatic signs”). The unusual profile of level of arousal might be seen
as indicative of the overall strength of dispositional representations.
For example, if a “depressed” modifier is observed, a person seems
to have learned that his/her dispositional representations are usually
not protective or even counter-productive; in this case, it is adaptive
that they don’t motivate as strongly. This reflects a learned helpless-
ness about the general lack of fit of the strategy to the context. The
person, however, is stuck in a “depressed” state not only because of
the rigidity of the strategy, but also because of the low arousal re-
flecting a lack of motivation to explore reflectively alternatives. This
implies that, before intervening in the “inner workings” of the basic
strategy (i.e. the various memory systems transformations discussed
in the previous section), the overall level of arousal has to be addres-
sed, with tools that range from chemical to self-regulatory, to rela-

86
tional and to contextual change. In fact, nothing in the professional
dispositional representations considered so far has dealt with context
itself.

The context of individual functioning: what a

single DMM assessment does not say
Protective strategies and their modifiers inform us about the fun-
ctional adaptation of an individual to the context in which they have
lived and live now. In a sense, through the DMM assessment of
an individual, the professional sees the imprint of context on that
individual’s functioning. Through a functional PDR, the understan-
ding of a disorder has already become systemic. But does the descrip-
tion of an adaptation (or lack of it) to danger say all there is to know
about the nature of that danger, and the relational sources of protec-
tion and comfort that exist in the context? And about the dangers
that one can incur while a family is trying to protect its members
(sometimes not equally)? Although DMM assessments derive in-
formation about an individual in a dyadic (and therefore systemic)
context, they are limited in their scope. For example, if a person has
adapted strategically to the risk posed by attachment figures that can
become unavailable unless one actively prevents the danger (for ex-
ample with an A3 strategy of compulsive caregiving), we know quite
a bit about how the person has organized, both behaviorally and
functionally, and can probably explain why the person, as a mature
man or woman, finds certain aspects of intimate relationships dif-
ficult (not having easy access to affective information about his/her
own desires and needs). But do we know anything about why the
parents tended to become unavailable unless cared for? Do we know
whether the current attachment figure, i.e. the romantic partner or
spouse has the same or similar problem, and therefore the strategy is
still relevant? In this case, an intervention to make the strategy more
nearly balanced (like a B strategy) might harm the relationship with
the partner. Or is the partner actually motivated to stay in the rela-
tionship, in which case the A3 strategy is redundant at best, and at
risk of becoming counterproductive? If we find a depressive modifier

87
 in our assessed individual, maladaptation might already exist. But we
might have been lucky, and caught the situation before the strategy
has exhausted its value. How do we tell if changing the individual’s
strategy is useful, useless or even harmful?

Family Functional Formulations:

Critical dangers for families and
critical causes for change
The most immediate and relevant context for individuals are the fa-
milies in which they live. The family is embedded in a social, geo-
graphical, economical, political context, but many of these systems,
especially during the early development, affect an individual through
the filter of the interactions within the family. Indeed, learning an
attachment strategy could be a theoretical way of conceptualizing
the learning about the features of the dangers in the larger environ-
ment as filtered through the family. A representation of how a family
functions is therefore highly relevant to choices of intervention for
distressed individuals. A family functional formulation is an inte-
grative PDR based on individual functional diagnoses of all family
members; it goes beyond the focus on an individual’s behavior and
perspective, representing an understanding of how the members of
a family function together to manage protection from danger and
reproductive functions. A family functional formulation specifically
addresses what is the danger the family protects from, together with
the costs/benefits ratio of this protective organization.

88
Functional diagnoses for each family member as
the basics for a family functional formulation
The behavior of family members is a source of privileged information
about safety and comfort because family is developmentally the first
source of protection and comfort for an individual. But as a small
baby behaves in ways that convey her distress, the family members
process the sensory input her behavior generates according to their
experience with danger. The family as a system will then generate
protective behaviors that will be implemented by specified indivi-
duals, according to situational choices reflecting specific learning by
the family. The array of family interactions around protection and
comfort is conceptualized by the DMM as the interplay of each in-
dividual family member’s strategy.
This is an argument for using clinically DMM developmentally
attuned assessments (Farnfield, Hautamäki, Nørbech, & Sahhar,
2010) for each family member, in order to get information about
an individual’s context when a mental disorder is diagnosed descrip-
tively within a family. For information about how the family organ-
izes to assign the task of implementing protective action among the
adults, the Parents Interview (Crittenden, 1981) is the DMM assess-
ment that, using the systematic probing of memory systems, looks
at how the parental subsystem organizes to protect the whole family.
The result of these assessments, coded blindly, is an array of strat-
egies that can then be assigned to the family genogram (therefore
keeping in mind the developmental constraints for each family
member’s strategy) and considered in terms of how they can func-
tion together to identify danger and implement strategic action to
protect the whole family from danger and give comfort to all the
members.

89
 Looking at the interplay of individual strategies in
a family
The complexity of family systems can possibly be considered in a
more organized way using the DMM principle of the priority of
protection from danger. The attachment strategy will characterize a
significant portion of each individual’s behavior, but its crucial fun-
ction is to let the individual be alert to information that can predict
danger, and mentally represent it in ways that dispose to protective
action. So the basic question that organizes a functional family for-
mulation is: what is the crucial danger that organizes the functioning
of each family member? Is it the same (or compatible) for various
family members? Or are the different family members’ organizations
to prevent danger leading them to behaviors that are incompatible,
so that what is protective to a family member becomes dangerous
for another?
For example, the parents of two young adult sons are oriented to
keep a close proximity to their sons, due to traumatic experiences
that lead them to underestimate the sons’ competence in self-protec-
tion. The sons are organized to maintain close proximity to attach-
ment figures, according to the behavior of the parents (the causes of
which are largely invisible in the present). But one of them, Son 1, is
trying to address some reproductive needs by forming attachments
outside the family (with sex as part of the relationship). The parents
represent this relationship outside the family as dangerous, and act
to limit it. Son 1 wants to protect his reproductive potential while at
the same time trying to keep the relationship with the parents, using
an A/C strategy of compulsive performance alternated with feigned
helplessness and seduction. Ultimately his strategy fails because in
this family context there is no way out of the dilemma of the in-
compatibility of protection and reproduction. Son 1’s strategies ap-
pear modified in a “disoriented” way, in which there is high arousal,
with a basic uncertainty about sources of reliable information and a
constant search for new information to act on (in often incoherent
ways). Son 2, in the context of parental reactions to the danger posed
by children’s reproductive motivations, curtails his own development

90
and reproductive behavior by sticking to the alliance with the par-
ents (to the point of fighting the brother), and the representation of
the distress involved in this stance become completely somatic, with
multiple medically unexplained physical complaints.

Critical dangers within a family

This vignette illustrates how the critical danger for the parents and
Son 2 is “children going out of the family”, and the critical danger for
Son 1 is “not getting reproductive opportunities”. These two dangers
can’t lead to compatible actions in this context. In fact, Son 1 (the
“minority” in the family) gets assorted descriptive diagnoses (mainly
personality disorders, but also anxiety disorders, sleep disturbances,
somatoform disorders). The parents act protectively, but they also
emphasize that Son 1 “must have something wrong” and the doctor
shopping is frantic. It could be argued that until the parents’ stra-
tegies for identifying danger are clearer (possibly with some under-
standing of their traumatic responses to current circumstances like
the normative adult behavior of Son 1), even individual treatment
of Son 1 is going to be extremely difficult, and Son 2’s complaints
are going to be largely ignored in terms of their interpersonal and
developmental meaning.

Integrating all PDRs in a Family Functional

Formulation to identify a critical cause of change
In general, the initial stage of a DMM-based Family Functional For-
mulation (FFF) will consist of: 1) the assessment of the strategies of
all family members, 2) an overall picture of the family considering
critical dangers for this family, with special attention to how the criti-
cal dangers for each family members compares to the others’ in terms
of compatibility. When a functional overview of the family systems
appears to be cohesive in terms of understanding: 1) how the family
organizes to identify and protect from similar or different dangers; 2)
how the protective functions are assigned to the various family mem-

91
 bers, then the FFF is ready to be integrated with all other relevant
PDRs. These would include: a history of the family, a clinical picture
(including one or more descriptive diagnoses for family members), a
functional analysis of how symptomatic or maladaptive behavior has
worked, and how clinical interventions have worked so far.
The aim of this integration is to identify a “critical cause of change”
(Crittenden & Ainsworth, 1989). If the family is actively using its
resources to protect from danger (even if its functioning is partly
incoherent and ultimately stalled), then it can be hypothesized that if
some parts of the system would be changed, this might change signi-
ficantly the state of the system. The “critical cause of change” would
be that part of the system that, if targeted by intervention, might
most economically restore the ability of the system to self-organize
and regulate around the goals of protection, comfort and reproduc-
tion for all members.
In the above example, when the nature of the unresolved traumas
of the parents is better understood and there is a plan for quieting
parents’ protective/cramping traumatic responses, the “critical cause
of change” might be Son 1 moving out of home. In turn, this might
facilitate the establishing of a sexual/reproductive partnership. If the
family is helped through the transition, and the expected danger is
prevented through alternate ways that don’t demand close proxim-
ity between family members, the protective potential of the family
might be retained, while the sons might access reproductive oppor-
tunities (and the overall distress might be reduced).
The idea of a critical cause of change as the principal aim of the
intervention supports a transition from a deficit-focused approach
to intervention to a strength-focused approach. Intervention is not
conceptualized by the DMM as a series of patches on a faulty situa-
tion, but as the most focused and economical action that maximizes
the family’s potential to self-repair and reorganization.

92
Family Functional Formulation as an integrated
PDR to orient treatment
The FFF is the map that orients a strength-focused approach to tre-
atment. A map represents the territory, but is neither complete, nor
directive in terms of what to do in the territory. One can trace a
route on the map, then discover previously unknown things on the
way, or find other smaller discrepancies with the map. The route
can be abandoned as the journey, by necessity or leisure, leads to
other places; then it can be reached again if getting to the intended
destination becomes urgent. A map facilitates such liberties during
the journey. Out of metaphor, a FFF is a tool for making detailed
predictions about families, observing results of therapeutic action,
falsifying hypotheses and re-orienting treatment. It is a complex re-
presentation of complex systemic functioning, but it is still specific
enough to allow for formulating falsifiable hypotheses. As such, it
can help to bring precision to representations of family functioning,
which are for many professionals the main object of clinical atten-
tion, but the complexity of which is often daunting. What is im-
portant is not to get the “right” representation of the family, but one
that is specified enough to be falsified and therefore corrected. The
process of this series of corrections, if shared in a relationship with
the family, could coincide with the treatment itself.

Personal DRs of therapists that dispose to

therapeutic or iatrogenic actions
This chapter, so far, has reviewed some crucial professional dispo-
sitional representations, that is, ways to make sense of information
about distressed people that dispose therapists to take therapeutic
action. The last part of the chapter will recapitulate systematically
some principles of DMM integrative treatment that have been used
throughout this chapter in an implicit way.
Before doing that, however, it is important to mention that there
are other dispositional representations relevant to how therapists act

93
 with patients. They haven’t been discussed so far because they are
not easy to generalize, and sometimes they are not considered a wor-
thy part of professional trainings. Therapists are human beings. As
humans, therapists have personal protective strategies just like all
others do. When a therapist enters a family system as a transitional
attachment figure (for the whole family, or for the members asking
for help), the FFF is supposed to include the therapist’s strategic set-
up if the predictions about therapeutic actions aim to be accurate.
Whenever the therapists’ strategies are an unknown entity, the FFF
can be reasonably complete as a description of a family before inter-
vention, but its function as a map to orient treatment is more limited
and potentially misleading. The therapist who is aware of her own
strategic organization can find more discrepancies between her vari-
ous representations of the clinical problem, and therefore have more
chances of productive integrative reflection.

Therapeutic responses: General

DMM principles of treatment
This chapter’s progression from individual descriptive diagnoses, to
individual functional diagnoses, to Family Functional Formulations
reflected mainly a review of professional dispositional representa-
tions, from the observation of behavior to the systemic functional
interpretation of behavior. But does this order of discussion reflect
the order of therapeutic actions as they occur clinically? Or does the
argument in favor of the FFF as the most integrated (and complex!)
professional dispositional representation imply that no therapeutic
action is to be taken before FFF is reasonably complete? The most
likely answer is no. The way a family is assessed shapes the relation-
ship between therapists and families, which immediately affects the
families (and the therapists).
The general DMM principles of treatments may be useful to re-
capitulate at this point, to highlight how the process of interven-
tion demands that therapists sort out their multiple priorities (dis-

94
posed by various PDRs) and choose actions that are contingent and
synchronous with the families they are working with. The order of
therapeutic actions can therefore vary considerably. This is fine, as
long as the process is reflectively informed by multiple PDRs, which
should orient to which actions can be considered therapeutic, and
which results can be considered beneficial, unavoidable side effects,
or iatrogenic damage.
So the order of these principles and the implied logical succession
of therapeutic action doesn’t mean that a therapist can’t start “from
the end” if things seem to advise that, as long as it is clear what is
missing and will have to be caught up with later on.
The general principles of DMM integrated treatment (Crittenden,
Dallos, Landini, & Kozlowska, in press) are the following:

1- Danger and safety

A request for help to a therapist defines a professional
relationship focused on protection from danger and relief from
distress. Families have their representations of danger and
safety, but the distress they are reporting suggests that these
representations are incomplete or include strongly transformed
information, in ways that make current adaptation difficult
or impossible. The therapists’ focus on danger and safety, and
the assessment of their representations in a family, will allow
intervention to stay focused on critical topics, be inclusive of
possible protective actions and avoid creating new dangers as
much as possible.

2- Therapists as attachment figures

The relationship between therapists and patients, being focused
on danger and safety, has all the features of an attachment
relationship, although it is supposed to be transitory and to end
when the health potential of the patients is restored. If therapists
are aware of this functional feature of their relationship with
patients and aim to act (like attachment figures) in the zone of
proximal development of their patients, they will maximize their
patients’ learning from intervention and limit their dependency
on the therapists’ prescriptions. Assessment that is respectful

95
 of the patients’ ways of representing their experience and
conveys the therapists’ interest in patients’ histories is crucial in
establishing the working basis for a therapeutic relationship.

3- Regulating Arousal
If some of the family strategies are chronically unfit to the
present context (appearing modified in the DMM assessments),
intervention will have to address how the arousal level is
chronically skewed as a consequence of this functional strategic
state. Some states of lowered, heightened, or suddenly changing
arousal might prevent other needed therapeutic changes, if not
addressed.

4- Quieting traumatic responses to current conditions

If some family member is responding to current conditions in
ways that are mainly shaped by unresolved representation of
past dangers, not integrated with a current adaptive strategic
organization, intervention will have to address the distinction
between past and present dangers, and between different
functions of various protective behaviors. If traumatic responses
to past dangers continue to affect current circumstances (either
by activating protective action towards dangers that are not
current, or by inhibiting useful protective action to present
dangers), other therapeutic changes might be impossible.

5- Increasing family members’ repertoire of protective strategies

The Family Functional Formulation might indicate that the
protective behavior repertoire of the family needs updating
to meet the current needs of the family. Usually this implies
the maximization of mental functioning potential of family
members, within the limits of their maturational abilities.
In other words, A and C strategies might be updated with
less extreme transformations of information, all the way to a
balanced functioning (i.e. a B strategy). Usually the point of
balance at which the intervention might stop is influenced
by the level of danger in the current family environment. The
more substantial the danger is the more efficient it is to use a

96
 less balanced strategy than B. It is important, however, that the
family has at least an implicit idea that the solution to the next
crises is in the area of considering discrepancies reflectively,
possibly in the context of an attachment relationship that fosters
reflection.

6- Reaching coherence and resilience

Practice in integrative reflection and clear communication is
the key to the family maximal potential of self-organization
and effective use of its resources. The ultimate end-point of any
intervention is creating the conditions for the family to learn
to identify discrepancies, communicate clearly about them, use
them as the starting point of collection of relevant information,
reflection on this information, and construction of an integrative
understanding of current conditions, with implication for
protective action. The whole intervention is best used as a model
of this process, with the therapist constructing and updating her
professional representations as discrepancies emerge in ways that
the family can see and learn from.
The application of these principles to specific families with their
problems is the fascinating “art” of therapy, which hopefully
can become more of a shared “science” as we, as a field, unravel
the intuitive and implicit processes that guide therapists to
spectacular successes or disastrous defeats. Some concluding
ideas about this application are discussed below, both to review
some of the most crucial content of this chapter and to point to
growing edges of DMM theory about treatment.

The presenting problem: a starting point, not a

goal
The presenting problem, which is sometimes turned into a descrip-
tive diagnosis, is an important starting point for intervention. Ho-
wever, it doesn’t define the ultimate goal of treatment and it is not
always necessary to define the opportunities for intervention. In fact,
prevention could be defined as all the interventions that promote

97
 health ahead of a presenting problem. Symptom reduction or extin-
ction can be important among intervention goals, but it doesn’t need
to be the only one, or to shape all the treatment rationale.

Working with families in their zone of proximal

development
The idea of therapists working in the zone of proximal development
of patients, just like attachment figures do, might sound strange,
especially if mental health interventions are not seen primarily as
teaching/learning tasks. However, as a therapist tries to implement
treatment principles, it might be rapidly observable if the attempt
is outside the zone of proximal development or instead is on target.
Just like mothers of infants can use infants’ protesting behavior as
a source of information to repair breaches in dyadic synchrony, the
therapists can use “errors” in their therapeutic actions to learn more
about the family zone of proximal development and adjust their ac-
tions. If therapists do this in a way that is visible to the patients,
they model a process of learning from mistakes that is ultimately one
of the main landmarks of balanced mental functioning and mental
health. As repair strategies are a crucial part of social skills, they are
critical in reaching coherence and resilience.
In more specific terms, working in the zone of proximal devel-
opment of patients has two aspects: 1) the choice of appropriate
techniques for regulating arousal, quieting traumatic responses and
increasing strategic repertoire; this choice should be coherent with
the FFF, and guided by the strategic functional diagnosis for each
family member; 2) the choice of the appropriate settings for the ap-
plication of the techniques, in terms of which family subsystems will
work with which therapists; this choice will be guided mainly by
how the FFF informs about the interests in concert with or in con-
flict within the family, the critical dangers and the possible critical
cause of change.
In general, DMM treatment proposes that families should be
treated as a resource, being the past or current life context of an in-
dividual. Protection by therapists of an individual against the family

98
should be avoided unless there is strong evidence that this is the only
viable option. When an individual is protected in ways that under-
mine his/her family relationships, the DMM would predict that the
intervention might have strong undesirable side effects, or even be
iatrogenically harmful.

Evaluating treatment
To assess this, all intervention should include forms of monitoring or
evaluation done by the working therapist as part of the intervention
itself, in a reflective integration process that can be both a tool and
a result of the treatment. Other forms of evaluation, however, are
highly relevant. Evaluation done by researchers that are external ob-
servers of interventions can increase knowledge about the processes
of change that are relevant to treatment (and potentially not visible
to therapists from within the treatment system), but also augment
the evidence base about outcomes of treatments, the unintended
harmful effects of therapy, and the active ingredients of change.

99
 References
Achenbach, T.M., McConaughy, S.H., & Howell, C.T. (1987) Child/adolescent
behavioral and emotional problems: implications of cross-informant correlations for
situational specificity. Psychological Bulletin, 101(2), 213–32.
Ainsworth, M.D.S., Blehar, M.S., Waters, E., & Wall, S. (1978) Patterns of
attachment: a psychological study of the Strange Situation. Hillsdale, N.J.: Erlbaum.
Belluck, P. & Benedict C. (2013). Psychiatry’s guide is out of touch with science,
experts say. New York Times, U.S. Edition, May 6, 2013.
Crittenden, P.M. (1981). Parents interview. Miami, FL (on file with author).
Crittenden, P.M. (1997–2005). School-age assessment of attachment coding manual.
Miami, FL (on file with author).
Crittenden, P.M. (2000). A dynamic-maturational model of the function,
development, and organization of human relationships. In R.S.L. Mills & L.Duck
(Eds.), Developmental Psychology of Personal Relationships (pp. 199–218). Chichester,
UK: Wiley.
Crittenden, P.M. (2005). The transition to adulthood attachment interview. Miami, FL
(on file with author).
Crittenden, P.M. (2008). Raising parents: Attachment, parenting and child safety.
Cullompton, UK: Willan.
Crittenden, P.M. & Ainsworth, M.D.S. (1989). Child maltreatment and attachment
theory. In D. Cicchetti & V. Carlson (Eds), Handbook of child maltreatment. New
York: Cambridge University Press.
Crittenden, P. M., Dallos, R., Landini, A., & Kozlowska, K. (in press). Attachment
and family therapy. London: Open University Press.
Crittenden, P.M., Kozlowska, K., & Landini, A. (2010) Assessing attachment in
school-age children. Child Clinical Psychology and Psychiatry, 14,185–208.
Crittenden, P.M. & Landini, A. (2011). Assessing adult attachment: a Dynamic-
Maturational approach to discourse analysis. New York: Norton.
Farnfield, S., Hautamäki, A., Nørbech, P., & Sahhar, N. (2010). DMM assessments
of attachment and adaptation: procedures, validity and utility. Clinical Child
Psychology and Psychiatry, 15(3), 313–28.
Heller, M.B. (2010). 'It was an accident waiting to happen!' An investigation into
the dynamic relationship between early-life traumas and chronic posttraumatic stress
disorder in adulthood. In M. B. Heller & S. Pollet (Eds.), The work of psychoanalysts
in the public health sector (pp. 140-155). New York, NY, US: Routledge/Taylor &
Francis Group.

100
Hughes, J., Hardy, G., & Kendrick, D. (2000). Assessing adult attachment status
with clinically-orientated interviews: a brief report. British Journal of Medical
Psychology, 73, 279–83.
Kwako, L.E., Noll, J.G., Putnam, F.W., & Trickett, P.K. (2010) Childhood sexual
abuse and attachment: an intergenerational perspective. Clinical Child Psychology and
Psychiatry, 15, 407–22.
Ringer, F. & Crittenden, P.M. (2007). Eating disorders and attachment: the effects of
hidden processes on eating disorders. European Eating Disorders Review, 15, 119–30.
Zachrisson, H.D. & Kulbotten, G. (2006). Attachment in anorexia nervosa: an
exploration of associations with eating disorder psychopathology and psychiatric
symptoms. Eating & Weight Disorders, 11, 163–70.

101
 Chapter 4: Endangered to
endangering – how can the
Modified Adult Attachment
Interview inform treatment in
prison?

Val Hawes, M.D., Consultant Forensic

Psychiatrist
Fens Unit, HMP Whitemoor, March,
Cambridgeshire, UK

Abstract
The Fens Unit is a therapeutic unit within a high secure prison de-
veloped since 2000 as part of a UK Government strategy for the as-
sessment and treatment of high-risk offenders diagnosed as suffering
from severe personality disorder.
The Modified Adult Attachment Interview has been used at the
Fens Unit with over 40 interviews having been completed. Just over
a quarter of these interviews have been fully analysed using DMM
coding and classification. These classifications show both consistent
features and a variety of patterns.
The main consistent feature is unresolved trauma i.e. that all the
offenders have experienced significant trauma during development,
particularly issues of neglect and abandonment, of physical abuse
by attachment figures and sexual abuse, either within or outside the
family. In many of the transcripts there is evidence of more than one

102
type of unresolved trauma e.g. physical abuse by father and sexual
abuse in care.
This consistency concerning trauma, contrasts with the variety of
classification patterns in these high-risk offenders. The majority of
patterns are high subscript i.e. lower half of the model but include
Type A (cognitive strategy), Type C (affective strategy) and combina-
tions of both A and C strategies including the integrated AC pattern
that is the DMM representation of psychopathy.
Recognition of unresolved trauma and the variety of self-protec-
tive strategies are consistent with other measures of the heterogeneity
of the population but also contribute to individualised treatment.

Corresponding author Val Hawes, M.D., Fens Unit, HMP Whi-

temoor, March, Cambridgeshire, UK, valhawes@doctors.org.uk

Introduction
This paper is one of a series describing practical applications of the
assessment tools in clinical use following their development within
the Dynamic Maturational Model of Attachment and Adaptation.
The contents of these papers were initially presented during a semi-
nar held to mark the 70th anniversary of the founding of the Swe-
dish School of Social Science at the University of Helsinki.
The paper will firstly summarize the development of and the
Adult Attachment Interview and some of the research relating to
its use particularly in clinical and forensic contexts. This will in-
clude reference to research conducted from the perspective of the
Dynamic Maturational Model of Attachment (DMM). The second
focus of the paper is the Fens Unit, a therapeutic unit within a high
secure prison in UK that is now part of the Personality Disorder
Offender Pathway. The Unit including the therapeutic programme
will be described. These two aspects will then by brought together
by summarizing some findings from the use of the Modified Adult

103
 Attachment Interview with prisoners on the Fens Unit. A detailed
case vignette will be used to illustrate the contribution of the AAI to
the development of clinical formulation for an individual prisoner
and subsequent progress in therapy.

The Adult Attachment Interview

The Adult Attachment Interview (AAI) was developed in the mid-
1980s by Carol George and other colleagues of Mary Main (George,
Kaplan, & Main, 1984-96). The aim was to explore the state of mind
of mothers in relation to attachment as compared with the quality of
attachment of their infants. The AAI is a semi-structured interview
that consists of a series of questions about childhood relationships
with attachment figures (usually parents) together with interviewer-
generated follow-up questions. The task for the interview subject is
to retrieve and reflect on memories of childhood while retaining as
much coherence as possible (Hesse, 1996) and this has the potential
to ‘surprise the unconscious’ (George et al., 1984-96). A short ac-
count of the administration and uses of the AAI has been given by
Farnfield, Hautamäki, Nørbech, & Sahhar (2010). The transcript is
then coded to produce a classification using the coding guidelines
developed by Main and colleagues (Main & Goldwyn, 1984-94) or
the DMM manual (Crittenden & Landini, 2011).
Over the decades since its introduction, the AAI has been used
in many settings with both normative and clinical populations. The
original model of attachment developed from the work of Mary
Ainsworth with infants included three categories – Type A, B and
C where Type B represents secure attachment; Type A avoidant and
Type C ambivalent. A fourth category was then added – Type D dis-
organized attachment (Main and Solomon, 1986). As research using
the AAI expanded to include a greater variety of non-normative sam-
ples, increasing difficulties were noted in fitting all transcripts into
this model. In an attempt to overcome this difficulty, Hesse (1996)
described a ‘cannot classify’ group and a Dutch study of personality-
disordered criminal offenders found that 53% of the transcripts in

104
that sample fell into this group (van Ijzendoorn et al., 1997). How-
ever other researchers have instead applied the ABCD categories of
infancy to the AAIs of adult subjects. AAI research with a UK high-
secure hospital population also raised both procedural and coding
challenges (Turton, McGauley, Marin-Avellan, & Hughes, 2001)
related to the extreme early experiences and psychological state of
subjects as well as the interview context in which subjects had given
their life history many times.
Having studied under Ainsworth and worked alongside Main
and colleagues, Patricia Crittenden taught the use and coding of the
AAI using the ABCD model in several European countries. As she
gathered transcripts of interviews carried out by clinicians working
with troubled clients, she began to develop the DMM approach and
made some changes to the interview content to develop the Modi-
fied AAI in use today by professionals using the DMM approach to
the study of attachment (current version, Crittenden, 2009). During
the course of the interview, the changes of topic introduce a gradual
increase in the degree of ‘threat’ within the questions as follows; ori-
entation to the speaker’s family, relationship with attachment fig-
ures, direct probes of normative events, direct probes of potentially
dangerous experiences; loss, integrative questions. While maintain-
ing awareness of issues of unresolved trauma and loss, Crittenden
added a number of additional concepts to the process of classifica-
tion. These modifiers are depression (not the same as clinical depres-
sion but evidence of a psychological process that limits the effective-
ness of the person’s self-protective strategy); disorientation (where
the speaker is unclear about the sources of information); intrusions
of negative affect (usually anger) and expressed somatic symptoms
(severe enough to disrupt the interview process). The use of the AAI
by clinicians working in clinical and forensic settings has made sig-
nificant contributions to the development of DMM theory and the
full DMM model owes much to the AAI transcripts of subjects in
clinical and forensic settings. The model is shown as Figure 1 (Farn-
field, Hautamäki, Nørbech, & Sahhar, 2010) and is described by
Hautamäki in the first paper in this monograph.
The Fens Unit is a therapeutic unit within a high secure prison
developed since 2000 as part of a UK Government strategy for the

105
 assessment and treatment of high-risk offenders diagnosed as suffer-
ing from severe personality disorder.
The Modified Adult Attachment Interview has been used at the
Fens Unit with over 40 interviews having been completed. Just over
a quarter of these interviews have been fully analysed using DMM
coding and classification. These classifications show both consistent
features and a variety of patterns.
The main consistent feature is unresolved trauma i.e. that all the
offenders have experienced significant trauma during development,
particularly issues of neglect and abandonment, of physical abuse
by attachment figures and sexual abuse, either within or outside the
family. In many of the transcripts there is evidence of more than one
type of unresolved trauma e.g. physical abuse by father and sexual
abuse in care.
This consistency concerning trauma, contrasts with the variety of
classification patterns in these high-risk offenders. The majority of
patterns are high subscript i.e. lower half of the model but include
Type A (cognitive strategy), Type C (affective strategy) and combina-
tions of both A and C strategies including the integrated AC pattern
that is the DMM representation of psychopathy.
Recognition of unresolved trauma and the variety of self-protec-
tive strategies are consistent other measures of the heterogeneity of
the population but also contribute to individualised treatment.

106
 Integrated True Information
(Type B)
True Cognition True Negative Affect

B3
B1–2 Comfortable B4–5
Reserved Reactive
A1–2 C1–2
Socially Facile/ Threatening/
Inhibited Disarming

Cognition A3–4 C3–4 Affect

(Type A) Compulsively Caregiving/ Aggressive/ (Type C)
Compliant Feigned Helpless

A5–6 C5–6
Compulsively
Promiscuous/ Punitive/
Self-Reliant A7–8 Seductive
Delusional
Idealization/
C7–8
Externally Menacing/
Assembled AC Paranoid
Self Psychopathy
False Positive Affect False Cognition
Integrated False Information
(Type AC)

Figure 1: Dynamic Maturational Model of Attachment and Adaptation

in adulthood (Copyright, P.M. Vrittenden, 2001)

Although there has been enormous growth in attachment-related

publications, there have so far been relatively few considering se-
vere clinical and/or forensic subjects from an attachment perspec-
tive. Crittenden has published studies of small series of subjects with
eating disorders (Ringer & Crittenden, 2007); mothers with bor-
derline personality disorder comparing ABCD and DMM classifi-
cations (Crittenden & Newman, 2010) and PTSD (Crittenden &
Heller, 2013). In the forensic field, there is a division between sexual
and violent offenders. Hudson-Allez in her book (2009) has descri-
bed the neuroscience underlying attachment and the consequences
in terms of psychopathology and a variety of sexually-motivated of-
fending patterns throughout the lifetime of a prototypical indivi-
dual. O’Reilly (2010) presented a study of sex offenders before and
after treatment and Haapasalo, Puupponen, & Crittenden (1999)
published a case study of a recidivist sexual offender. Two papers
have reported on AAI-informed work with violent men in probation
setting (Renn, 2002; Worley, Walsh, & Lewis, 2004). Other studies

107
 of violent offending have considered links between attachment and
psychopathy. Flight and Forth (2007) used a self-report assessment
of attachment with adolescents diagnosed as psychopathic by PCL-
YV. Frodi and colleagues (2001) included the AAI in their assess-
ment of adult psychopathic offenders. More recently Nørbech, Crit-
tenden and Hartmann (2013) have published a detailed case study
of an offender with history of very serious violence and diagnosis
of psychopathy, comparing his complex self-protective strategy (as
indicated by DMM classification of his AAI) with the findings on
Rorschach assessment.
In their paper discussing some of the difficulties of AAI research
in a high-secure hospital setting, Turton and colleagues (2001) noted
the extreme early experiences of their subjects. Others have noted
clear links between maltreatment in childhood, attachment diffi-
culties and adult psychopathology. Alexander (1992) wrote from a
mainly theoretical perspective but with reference to clinical implica-
tions on the application of attachment theory to the study of sexual
abuse. Minzenberg and colleagues (2006) used self-report measures
to assess outpatients with a diagnosis of borderline personality disor-
der. They concluded that current interpersonal problems and symp-
toms of these subjects showed disturbances of adult attachment that
were strongly related to childhood maltreatment. De Zelueta (2006)
has described the development of traumatic attachment in children
with vulnerability to development of chronic PTSD later and she
has developed the Traumatic Attachment Induction Test to aid as-
sessment and treatment of these disorders.
Bowlby was himself a psychoanalyst and in some of his writings
described psychotherapeutic approaches to attachment issues (e.g.
Bowlby, 1977). He was also very aware of the relevance of this in
the forensic field in his paper on juvenile thieves (Bowlby, 1944).
In recent years, other attachment researchers have turned their at-
tention more to treatment. Peter Fonagy working with Anthony
Bateman and collaborating with many others has written extensively
(e.g. Fonagy & Bateman, 2008) about the development of border-
line personality disorder due to combination of early disruption of
attachment relationships and later traumatic experiences. Mentali-
zation-based treatment (MBT) aims to encourage the development

108
of mentalization and its maintenance when the attachment system
is activated. Following on from this, there have been a number of
randomized control trials of MBT e.g. with partial hospitalization
(Bateman & Fonagy 2008) and with outpatients (Bateman & Fon-
agy 2009). MBT has also been applied in a treatment programme
for individuals with comorbid antisocial and borderline personality
disorders (Bateman & Fonagy, 2008). Levy and colleagues (2006)
have also developed treatment for borderline personality disorder,
assessing change in attachment patterns and reflective function (as
indicated in AAI) in response to transference-focused psychotherapy.
For offenders, almost all the main treatment programmes in current
use in custodial and probation settings, are cognitive behavioural
in approach. However Crittenden (2005) has raised the possibility
of harmful effects from such treatment for individuals with mainly
cognitive processing as shown by AAI and has suggested that the
DMM offers a more comprehensive approach to fitting treatment to
the needs of those with significant psychopathology. Van den Berg
and Oei (2009) have written of the difficulties encountered in work
with severely psychopathic forensic patients from the perspective of
both attachment theory and mentalization-based therapy.

The DSPD programme in UK

including the Fens Unit
In the wider context of increasingly risk-adverse societies, governme-
nts and professionals have been concerned to identify and treat and/
or manage those individuals who present the highest risk of causing
serious harm to other citizens. It has been recognized that a signifi-
cant proportion of such individuals are found on assessment to meet
criteria for several personality disorders and/or psychopathy. Howe-
ver it has also been recognized that while there is much evidence of
the effects of severe personality disorder for the individual and wider
society, the evidence base concerning effective treatments is limited
(Warren, 2003; Duggan, 2007). One clear objective of the UK go-

109
 vernment in setting up the DSPD (Dangerous and Severe Persona-
lity Disorder) Programme was ‘the establishment of a comprehen-
sive and continuing programme of research into the management
of people with severe personality disorder to support development
of policy and practice’ (Home Office/DoH, 1999). An important
existing template for this programme was the TBS system in the
Netherlands but it was unclear to what extent that approach could
be transferred to the UK.
In the very early stages of the programme, criteria were established
to determine whether an individual should be considered dangerous
by reason of personality disorder. To fulfill these criteria, there must
be evidence of the following:
• High risk (on actuarial measures) of violent and/or sexual
reoffending that is likely to cause physical or psychological harm
from which it will be impossible or difficult for the victim to
recover.
• Severe personality disorder as indicated by evidence of
psychopathy (as measured by the Psychopathy Checklist-
Revised) or two or more DSM personality disorders.
• A link between risk and personality disorder.

At a practical level, the DSPD programme developed four sites

in high secure settings – two in high secure hospitals and two in
prisons. The programme has been carefully monitored from cen-
tral government and evaluated independently. Over time there has
been increasing realization of the need to develop similar services
for personality-disorders offenders at all levels of security from the
community upwards. This led to the decision to discontinue the two
DSPD services in high secure hospitals and to divert the funds thus
released into the development of services in lower category prisons
and in the community. The remaining DSPD services in high secure
prisons have thus become the upper end of the Personality Disorder
Offender Pathway.
The first of the high secure sites to become operational was at
HMP Whitemoor in Cambridgeshire in eastern England with the
adaptation of an existing residential area of the prison to include of-
fices and therapy rooms. This service (usually called the Fens Unit)

110
has been working with prisoners since September 2000, initially of-
fering assessment only but since 2003, a full programme of treatment
(see below and Appendix 1). The Unit has capacity for 65 prisoners
who are resident in three inter-connected areas. From the beginning
of the service, the Unit has been staffed by prison officers with clini-
cal input from NHS-employed mental health professionals. This has
involved the development and maintenance of a transdisciplinary
team and all significant decisions being taken by clinicians and pris-
on officers conferring together. While individual therapy sessions are
conducted by clinicians, all group sessions are facilitated by both
clinicians and prison officers. Prison officers also have a vital role in
providing informal support to prisoners. (Fox, 2010.)
The prisoners are all adult males who are serving indeterminate
custodial sentences i.e. at the time of sentencing, they were informed
how long they must serve as punishment and retribution but release
thereafter depends on evidence of risk reduction. On return to the
community, all such offenders are subject to indefinite probation
supervision. Some of the prisoners have been in the early stages of
their sentence following conviction for murder or multiple violent
and/or sexual offences. Others have already served longer than the
period set by the judge but have been unsuitable for other prison
programmes or have failed to progress despite completing such pro-
grammes. Some others have been given relatively short minimum
terms but have behaved in ways that indicate serious dynamic risk
issues e.g. repeated assaultive behaviour in prison.
From the inception of the DSPD programme, it was agreed that
each of the high secure sites would develop its own approach to the
treatment of individuals meeting criteria for inclusion in the treat-
ment programme. The Fens Unit developed an integrated cognitive
interpersonal model with the aim of meeting multiple treatment
needs in a diverse group of prisoners meeting DSPD criteria (Sarad-
jian, Murphy, & McVey, 2010).
The residential assessment for prisoners lasts 4 months and those
meeting DSPD criteria are offered a place in treatment. As all main
aspects of treatment are psychological, it is vital that prisoners taking
part give informed consent to this. The treatment programme cur-
rently takes 4 ½ years – prisoners who consistently fail to attend ses-

111
 sions, who fail to show some evidence of internal change or who lose
capacity to consent for any reason are considered for discharge. The
majority of prisoners starting treatment do complete the programme
with at least some clear evidence of internal change. It is expected
that there will be some outstanding treatment needs, at the very least
to demonstrate the maintenance of change on progression to other/
lower security settings. As no treatment completers have yet returned
to the community, it will be many years before outcomes in relation
to recidivism are achieved.
From the beginning of the service, it was accepted that many of
the prisoners would have experienced interpersonal trauma during
their early lives and that that trauma would have contributed to the
development of personality disorder. This hypothesis has been con-
sistently confirmed over the years but with wide variation in the na-
ture and degree of trauma suffered. For a few, this has been mainly
emotional through repeatedly being involved in highly dysfunction-
al family relationships, for others there have been experiences of se-
vere physical abuse and/or sexual abuse, for others a combination of
emotional, physical and sexual abuse both within the family and in
other settings e.g. in care or boarding school. A significant number
of men have reported being sexually abused by adult women, often
in early adolescence.
During the early stages of treatment, the emphasis is on the de-
velopment of trust and a therapeutic alliance with the individual
therapist and the wider team. Given the histories of many prison-
ers, this process may be prolonged and difficult but with the aim
of working through difficulties as they arise. The establishment of
at least a degree of trust is vital to therapeutic work to address the
individual’s traumatic experiences towards the development of self-
compassion. Group therapy also contributes to the work of address-
ing trauma and provides a setting for improvement of interpersonal
relationships, particularly through the unstructured Cognitive Inter-
personal Groups. Other groups aim to challenge distorted thinking
by introducing the concepts of Schema Therapy and to encourage
knowledge of and access to a wide range of emotional experience
through Affect Regulation Groups. It is only in the last 2 years of
the programme, that prisoners overtly address their own offending

112
behaviour through Offence Focused Therapy. At that stage they also
work to address their past and current addictions and excessive ap-
petites and to understand the problems they have experienced in
interpersonal, including intimate, relationships. Prisoners remain in
the same group throughout treatment but work with a number of
clinician and prison officer group facilitators.
Although the main emphasis of the treatment programme is on
psychological treatment, the transdisciplinary team has recognized
that a significant number of prisoners are hindered in their participa-
tion by ongoing distrust with hypervigilance or by frequent and/or
severe affective dysregulation. Pharmacological treatment has been
regularly used on a short or medium term basis to facilitate engage-
ment in therapy for those individuals. Medication has also been used
in the treatment of comorbid conditions. These have included devel-
opmental conditions such as Attention Deficit Hyperactivity Disor-
der or Tourette syndrome, Axis I disorders such as bipolar disorder or
obsessive-compulsive disorder or severe symptoms of Chronic PTSD
(Hawes, 2010).

Use of the Adult Attachment

Interview on the Fens Unit
In the light of the characteristics of prisoners being offered treatment,
attachment theory and the use of the AAI to facilitate understan-
ding of attachment-related trauma was clearly relevant. A number
of senior clinicians undertook training in the use of AAI using the
DMM approach and completed interviews with a small number of
individual prisoners. Subsequent coding of the interview transcripts
confirmed expectations that these would show significant psycho-
pathology, but also provided information about the self-protective
strategies used by these individuals. These strategies had not been
readily apparent from standard clinical interviews and assessments.
Following these initial findings, a number of prisoners placed on
the Fens Unit were invited to complete the AAI as part of the as-

113
 sessment stage of their placement on the Unit. Other prisoners have
been interviewed at various stages of the treatment programme. Two
prisoners interviewed in the early stages of the use of the AAI on the
Unit were re-interviewed using the AAI Form B developed by Crit-
tenden (2006). Between 2004 and 2011, 46 interviews have been
completed, 29 of these during the assessment phase of placement
on the Unit. Of these 16 have been fully classified, all by groups
of trained coders as part of the DMM training and reliability pro-
gramme.
All of the transcripts so far classified show significant unresolved
trauma from a variety of causes:
• Abandonment by or separation from parents
• Witnessing domestic violence; experiencing physical abuse
• Sexual abuse by carers and/or strangers
• Emotional abuse, physical and emotional neglect.

This unresolved trauma was expressed in a variety of ways – some

speakers were preoccupied with it, others dismissed its significance
for their life, others showed evidence of attempting to manage the
trauma in a variety of ways. Several of the transcripts showed some
evidence of depression as recognised by the DMM i.e. discourse cha-
racteristics that indicate that the person was unable to use his self-
protective strategy fully.
In terms of classification, a wide range of strategies was found
with over-representation of A patterns and blended or alternating
A and/or C patterns. None of the AAI transcripts showed secure or
normative attachment patterns, i.e. from the top of the model; a very
few showed milder pathology but still with unresolved trauma; the
majority showed patterns indicating severe psychopathology. The
following paragraphs include some brief examples of these patterns
together with a few details of background and offending.
• A4 compulsive compliance with unresolved trauma for
abandonment. Mr W was brought up by his maternal
grandparents in a rural area of a third world country. He was
a ‘good boy’ who feared loss of approval or punishment. He
repeatedly stated his belief that his parents had sent him to his
grandparents as a baby for the sake of his health and that he held

114
 no negative feelings about that. He moved to live with his father
in UK at age 16 and did not really meet his mother until age
18. He then became involved with delinquent peers (probably
to achieve acceptance) then was seriously violent, possibly in an
outburst of anger.
• C3 threateningly angry with unresolved trauma for abuse. Mr X
was angry and preoccupied throughout the interview with the
angry and punitive behaviour of both parents. At a later stage
of treatment, it became clear that it was his anger towards his
mother that was more complex and a probable major factor
in his offences against women. He also displayed deceptive
behaviour – he lost a significant amount of weight by concealing
starving and vomiting with the aim of achieving transfer to
hospital.
• A7 delusional idealisation with unresolved trauma and loss. Mr
Y was brought up by a single mother and from an early age, he
and his younger sister were at home while their mother went
out to work. One evening when he was 8, it was the police who
came to the door – his mother had died in an accident and
the children were taken away to live with relatives. He spoke
of his mother in very idealised terms but otherwise was quite
detached through much of the interview. However he broke
down and was unable to speak for several minutes as he talked of
his mother’s death. At a later point in the interview there was a
very brief flash of anger indicating an intrusion of negative affect
leading to the hypothesis that such an intrusion was the likely
cause of his brutal attack on a woman while drunk.
• A8 externally assembled self with multiple unresolved traumas. Mr
Z had been removed from his mother and placed in residential
nursery very soon after birth. He remained in the nursery
until he was 3 (i.e. without any attachment figure) when he
was placed in a children’s home where he thought of the house
parents as his parents. However there was little truly personal
care and he was repeatedly sexually abused by older boys. He
went on to quite varied delinquency but including sexual
offences against children.

115
 The contribution of the AAI to
treatment
The treatment programme of the Fens Unit as summarised above
and as set out in chart form in Appendix 1 is well suited to meet the
treatment needs of individuals as revealed by the AAI as well as by
formal aspects of DSPD assessment and ongoing clinical observa-
tion. These treatment needs and the aspects of the programme most
relevant to each area of need are summarised in the following table:

Treatment need Relevant aspect of treatment

Need for safety and interpersonal trust Individual therapy, closed groups, length of
in relationships stay on residential unit

Major focus of first 2 ½ years of therapy

Need to resolve traumatic experiences
individual + Schema Therapy

Need for corrective emotional experi- Exploration of affect in individual work +

ence Affect Regulation Group

Need for change in distorted thinking Schema Therapy + Offence Focused

about past and present Therapy

Relative stability of prisoner + staff with

Need for behavioural change access to formal and informal support as
needed

Table 1: Treatment needs and relevant aspects of treatment

An area of treatment need to which the AAI can make a very specific
contribution is that related to the need for a corrective emotional
experience.
Wilkinson (2010) in his account of the inpatient assessment and
treatment of an adolescent girl, has described clearly the importance
of differentiating the patterns of anger and aggression with A and C
strategies. With the higher numbered A strategies, anger is normally
inhibited most of the time but may suddenly emerge as an intru-
sion of negative effect, sometimes of such severity that others are at
risk and urgent intervention is demanded. With C strategies, anger
is much more readily expressed, sometimes in exaggerated terms,

116
sometimes in a more controlled way and both patterns may alternate
with appealing or seductive behaviour that tends to involve others in
attempts to calm or resolve situations.
For many of the men placed on the Fens Unit, anger (and associ-
ated aggression) is the most accessible emotion and an important
aspect of the therapeutic work (both formal and informal) is to help
prisoners to have access to a much wider range of emotions then
allow themselves to experience the more vulnerable emotion that
lies beneath the anger e.g. fear and desire for comfort or grief from
abandonment or loss. Although there are some prisoners (e.g. Mr X
in the example above) whose main self-protective strategy is on the
C side of the model, a higher proportion of classified AAIs show a
high-numbered A strategy or combined A and C strategies (in either
blended or alternating form).
Those with high-numbered A strategies often present as calm and
emotionally detached. However any type of increased stress e.g. be-
ing challenged in a group session, may trigger a sudden angry reac-
tion. This may be expressed in a variety of ways – walking out of
group, biting sarcasm, a verbal outburst or overt aggression. Such an
intrusion of negative affect will almost certainly be an indication of
the usually hidden rage that was more fully expressed in that man’s
offending. The prisoner concerned will often then feel great shame
but with further exploration and the support of staff and peers, such
an intrusion can be a vital step towards emotional change.
It is these prisoners with higher-numbered A strategies who would
be particularly poorly served by offending behaviour programmes
with a cognitive behavioural approach. Provided that the programme
content is adequately understood by such a prisoner, his cognitive
strategy and self-control will be further strengthened with no oppor-
tunity to acknowledge or explore the rage that still has the potential
to cause great harm.
Those prisoners with combined A and C strategies, particularly in
blended form, are closest to the DMM pattern of psychopathy where
false cognition and false affect are so combined as to give a superficial
impression of integration. Such prisoners also score highly on the
Psychopathy Checklist-Revised or PCL-R (Hare 2003). An example
of such a presentation is given in the case vignette below and this

117
 has many similarities to the case described by Nørbech et al. (2013).
A frequent presentation with such individuals is of invulnerability.
They are able to describe past histories of severe abuse (with clear
indications of unresolved trauma in their transcripts) but with denial
or minimisation of the fear and physical/emotional pain experienced
and a high level of vigilance against any threat of further harm or
indication of disrespect. Any anger expressed is often in the form
of hostility in response to therapeutic challenges to the invulnerable
presentation or as fantasies and threats of sadistic revenge on past
abusers. The transdisciplinary team of the Fens Unit recognises that
such prisoners represent a major therapeutic challenge but among
those so far treated, a number have achieved definite cognitive, affec-
tive, interpersonal and behavioural change. Factors that contribute
to such change are the length of the treatment programme, the com-
bination of individual and multiphase group therapy, the emphasis
on resolution of personal trauma before offending is addressed, sta-
ble group membership and the ready availability of support from
clinicians, prison officers and peers.

Vignette – Joey’s story

(The individual on whose history this vignette is based has consented
to use of this material)

Joey is a white man in his 50s. He often chooses to keep to himself but
can be highly entertaining in conversation with the ability to tell down-
to-earth stories or make witty remarks. In more serious conversation, it
is clear that he is intelligent and has a wide knowledge of current events
and of contemporary literature. He may talk about his latest painting
project and there are examples of his work in some of the prison corridors.
He has a strong sense of a spiritual dimension of life – born a Roman
Catholic, he was a Buddhist for a number of years and for the past
decade, he has been a practicing Muslim. He writes regularly to friends
and every week he telephones his mother and his adult son. These various
strengths have developed in the context of half his adult life having been
spent in prison.

118
Joey’s early life
Anyone meeting Joey during his early life would not have been surprised
at his subsequent prison history. He grew up in an inner city dockland
area that was still scarred by WWII bombing. His father was always in
work but drank much of his wages and resented being trapped into mar-
riage by the unplanned pregnancy that led to Joey’s birth. Other child-
ren followed and Joey’s early memories are of living in one room and of
nappies being boiled over the fire. When he was a little older, the family
moved to a slightly bigger home but they were still very poor – he would
go with his mother to collect second hand goods from homes in a slightly
more affluent area then help her to sell them on a market stall. When his
father came home drunk at night, he would get Joey out of bed, beat him
and send him back to bed. Joey was curious about the world and began
to explore by himself, sometimes being away from home on his own for
hours at a time and sometimes taking his younger siblings with him. He
was well known in his neighbourhood and at the age of 4, a neighbour
sexually abused him and continued to do that regularly for several years.
Joey enjoyed school and being eager to learn, he also spent time in the
local library. Children from a variety of backgrounds attended the same
school – more than once Joey befriended a boy from a middle class home
and learned that there were homes very different from his own but these
friendships never lasted long. Joey was also influenced by boys from simi-
lar families to his own and through friends became involved in sexual
activity with men when he was 11/12. Some of this involved contact
with a semi-organized group of men who wanted sex with young boys.
Joey also had regular contact with a businessman who gave him clothes
and presents in exchange for sex.

Work, relationships and offending

On leaving school, Joey went to sea and sailed to many areas of the
world. He also learned cooking and on returning to England he worked
as an under-chef. At 18, his girlfriend was pregnant and the marriage
was arranged but Joey instead went to prison for 2 years. On his release,

119
 he attempted to maintain the relationship but instead committed 2 rob-
beries and spent a further 4 years in prison. During that sentence, he met
a slightly older professional woman, a mutual attraction developed and
they were married about a month after his release from prison. This mar-
riage opened the door to much that Joey had long aspired to – a loving
relationship, a comfortable home, social relationships with well-educated
people, ready access to art galleries, theatres etc. However, he was still
haunted by the many traumatic experiences of his early life - thoughts
and memories of these were often with him and increased rather than de-
creased over time. He was delighted by the birth of a son and internally
even less stable leading to another offence and short period of imprison-
ment. After this he returned home but with the marriage under strain
and Joey then effectively ended it by committing a more serious offence.
On release from that prison sentence, he returned to his home area
feeling fear and despair and resorting to alcohol for relief. He was able
to work but spent much of his time drinking on his own, with family
members and with a new partner. He feared being attacked and was still
haunted by memories of his own past trauma with a gradual build up of
stress that then ’exploded’ in very serious assaults on his partner and her
teenage daughter. This time he received a life (indeterminate) sentence.
After recovery from her injuries, the partner visited him in prison un-
til her alcohol-related death 3 years later. Joey spent 18 years in prison
during which time he had treatment in a therapeutic community and
cognitive-behavioural programmes. He was considered to have made
good progress and to have achieved good insight into his offending. He
was released under probation supervision and at first seemed to be doing
well but once again a combination of traumatic memories and current
relationship difficulties led to a build up of stress and a further serious
offence leading to another indeterminate prison sentence.

Joey’s AAI
During his early months on the Fens Unit, Joey was interviewed using
the Modified AAI. The interview was transcribed and then classified
some time later by a group of DMM/AAI coders. Like many interviews
with forensic clients, the classification is complex. The main features are:

120
• Depression – brief glimpses of despair and a sense of being at the
mercy of events rather than able to actively direct his own life
• Unresolved trauma – physical abuse and neglect in his family;
sexual abuse outside the home
• Unresolved loss – his ex-partner, also repeated incidents when his
own life had been threatened.
• Blended AC strategy with high level of distortion – close to DMM
psychopathy
• The A part of his strategy included delusional idealisation of his
mother i.e. idealisation that overlooked her failure to protect him.
The C part of the strategy included anger and seductiveness, also
triangulation i.e. being caught up in conflict between his parents.

Childhood episode as key to Joey’s offending pattern

In describing his relationship with his mother, Joey described an episode
when he was about 8 that he later recognized as providing a key to un-
derstanding parts of his offending pattern. The episode began with him
playing army games with another boy on waste ground near their homes.
They had made ‘foxholes’ and Joey was in one of these when his friend
kicked it in so that Joey was briefly smothered in earth. He struggled out,
picked up a stone and angrily threw it at his friend, hitting the other
boy’s head. He then went on playing by himself for a time before heading
home. When he got there he found that his mother was at the friend’s
house. As he greeted her, she hit him hard across the face (probably to
save face in front of the other boy’s mother). Joey felt betrayed and angry
– he ran home, stole money from his mother’s purse then travelled by bus
many miles from home. He felt increasingly miserable as the evening
wore on and it started to rain but he then saw a police officer and went
to him to ask for help. He was taken to the police station, given tea and
biscuits and was then taken to the home of an elderly woman for the
night. There he had more food then a warm and comfortable bed for the
night – very different from his home. In the morning he played in an
orchard with a dog and two other children. He tried to hide when his
father came to collect him but was taken home, expecting to be severely

121
 beaten when he got there but this time his mother intervened to protect
him from punishment.
Aspects of this episode that have been repeated in his offending are do-
ing something against his own ‘code’ of behaviour (throwing stone at his
friend); feeling betrayed by a woman (being hit by his mother); deliber-
ately committing a crime (stealing from his mother’s purse) then running
away from the scene of the crime; giving himself up to police (seeking
help from the police officer) then feeling safe once in custody + accepting
his need to be punished (the home of the elderly woman).

Joey’s progress in treatment

Joey has made clear progress in treatment and this will be summarized
in terms of the treatment needs common to prisoners in treatment on the
Fens Unit as listed above:
• Need for safety and interpersonal trust in relationships – More able
to acknowledge attachment to therapist
• Need to resolve traumatic experiences – Less preoccupied with
himself as victim
• Need for ‘corrective’ emotional experience – More in touch with
anger and sadness
• Need for understanding of own history + offending  progress
towards reflection and integration – Fuller acceptance of himself as
offender with recognition of thoughts + feelings leading to offending
• Need for behavioural change – More open about his coping strategies
and able to challenge dysfunction in others

Although Joey has made very definite progress in treatment, he still

faces the prospect of more years in custody. There is no ‘happy ending’ –
progress towards regaining some of what had been lost through trauma
(to himself and through him to others) brings both relief and sadness.

122
Conclusion
In 2000, the Fens Unit became the first of four services to be develo-
ped in high secure settings as part of the UK Government strategy for
the management of high-risk personality disordered offenders. Each
of these services was developed separately but with oversight from
central government. While clearly intended for the most dangerous
offenders, there were initially very limited services for offenders who
did not meet DSPD criteria. Over time a number of new initiatives
and redevelopments have led to a more coherent hierarchy of ser-
vices for personality disordered offenders from the community th-
rough levels of security to the two remaining services in high secure
prisons – the Personality Disorder Offender Pathway.
Since 2003, the treatment programme of the Fens Unit has been
further developed and refined and at the time of writing is expected
to continue to operate in its present form. There is a steady stream
of new referrals and a slow but steady turnover of prisoners as some
complete treatment and move on to be replaced by new admissions.
The transdisciplinary team is made up of some members who have
been in post for several years and other newer arrivals ensuring both
consistency and refreshment. Overall there has been a gradual con-
solidation of skills for dealing with damaged and dangerous men
while maintaining both security and compassion.
The Modified Adult Attachment Interview provides a rich source
of information about such men, supplementing material obtained
by standard clinical and forensic assessment approaches. The tran-
scripts already classified have provided important insights that have
the potential to contribute to formulation and treatment for those
individuals. In the next few years, it is hoped that other transcripts
will be classified and that further interviews will be completed with
the establishment of a fuller understanding of the self-protective
strategies of men who have progressed from being in danger to en-
dangering others.

123
 References
Alexander, P. C. (1992). Application of attachment theory to the study of sexual
abuse. Journal of Consulting and Clinical Psychology, 60, 2, 185-195.
Bateman, A.W. & Fonagy, P. (2008). 8-year follow-up of patients treated for
borderline personality disorder: mentalization-based treatment versus treatment as
usual. American Journal of Psychiatry, 165, 631-638.
Bateman, A.W. & Fonagy, P. (2008). Comorbid antisocial and borderline personality
disorders: mentalization-based treatment. Journal of Clinical Psychology, 64, 181-194.
Bowlby, J. (1944). Forty-four juvenile thieves: Their characters and home lives.
International Journal of Psychoanalysis, 25, 1-57.
Bowlby, J. (1977). The making and breaking of affectional bonds. British Journal of
Psychiatry, 130, 201-210, 421-431.
De Zelueta, F. (2006). Inducing traumatic attachment in adults with a history of
child abuse: forensic applications. British Journal of Forensic Practice, 3, 5-15.
Crittenden, P. M. (2006). AAI Form B. Unpublished manuscript, Miami, Family
Relations Institute.
Crittenden, P M (2009). English AAI. Unpublished manuscript, Miami, Family
Relations Institute.
Crittenden, P. M. & Heller, M. B. (2013). Chronic PTSD and attachment: A
comparison study of self-protective strategies in patients with PTSD, mixed diagnoses and
no diagnosis. Manuscript submitted for publication.
Crittenden, P. M. & Landini, A. (2011). Assessing Adult Attachment: A Dynamic-
Maturational Approach to Discourse Analysis. New York, NY: Norton.
Crittenden, P. M. & Newman, L (2010). Comparing models of borderline
personality disorder: Mothers’ experiences, self-protective strategies and dispositional
representations. Clinical Child Psychology and Psychiatry, 15(3), 433-451.
Duggan, C., Huband, N., Smailagic, N., Ferriter, M., & Adams, C. (2007). The use
of psychological treatments for people with personality disorder: A systematic review
of randomized controlled trials. Personality and Mental Health, 1, 95-125.
Farnfield, S., Hautamäki, A., Nørbech, P., & Sahhar, N. (2010). DMM assessments
of attachment and adaptation: Procedures, validity and utility. Clinical Child Psychology
and Psychiatry, 15(3), 313-328.
Flight, J. I. & Forth, A. E. (2007). Instrumentally violent youths: The roles of
psychopathic traits, empathy and attachment. Criminal Justice and Behaviour, 34,
739-751.

124
Fonagy, P. & Bateman, A. (2008). The development of borderline personality
disorder – a mentalizing model. Journal of Personality Disorder, 22, 4-21.
Fox, S. (2010). The role of the prison officer - dangerous and severe personality
disorder in the prison system. In N. Murphy & D. McVey (Eds.), Treating personality
disorder: Creating robust services for people with complex mental health needs. Hove, UK:
Routledge.
Frodi, A., Dernevik, M., Sepa, A. Philipson, J., & Bragesjö, M. (2001). Current
attachment representations of incarcerated offenders varying in degree of
psychopathy. Attachment & Human Development, 3, 269-283.
George, C., Kaplan, N., & Main, M. (1984-1996). The Adult Attachment Interview
(3rd ed.). Unpublished manuscript, Department of Psychology, University of
California, Berkeley.
Haapasalo, J., Puupponen, M., & Crittenden, P. M. (1999). Victim to victimizer:
The psychology of isomorphism in a case of a recidivist paedophile. Journal of Child
Sexual Abuse, 7, 97-115.
Hare, R. (2003). Hare Psychopathy Checklist-Revised (PCL-R) (2nd ed.). Toronto:
Multi-Health Systems.
Hawes, V. (2010). The role of the psychiatrist in treating personality disorder. In N.
Murphy & D. McVey (Eds.), Treating personality disorder: Creating robust services for
people with complex mental health needs. Hove, UK: Routledge.
Hesse, E. (1996). Discourse, memory and the Adult Attachment Interview: a note on
the emerging ‘cannot classify’ category. Infant Mental Health Journal, 17, 4-11.
Hesse, E. (1999). The Adult Attachment Interview: Historical and current
perspectives. In J. Cassidy & P.R. Shaver (Eds.), Handbook of attachment: Theory,
research and clinical applications. New York, NY: Guilford.
Home Office/Department of Health (1999). Managing dangerous people with severe
personality disorder: Proposals for policy development. London: Home Office.
Hudson-Allez, G. (2009). Infant losses; Adult searches. London, UK: Karnac.
Levy, K.N., Meehan, K.B., Kelly, K.M., Reynoso, J.S., Weber, M., Clarkin, J.F.,
& Kernberg, O.F. (2006). Change in attachment patterns and reflective function
in a randomized control trial of transference-focused psychotherapy for borderline
personality disorder. Journal of Consulting and Clinical Psychology, 74, 1027-1040.
Main, M. & Goldwyn, R. (1985-1994). Adult attachment scoring and classification
system. Unpublished manuscript, Department of Psychology, University of California
at Berkeley, Berkeley CA.
Main, M. & Solomon, J. (1986). Discovery of an insecure disorganized/disoriented
attachment pattern. In M. Yogman & T. B. Brazelton (Eds.), Affective development in
infancy (pp. 95-125). Norwood, NJ: Ablex.

125
 McGauley, G., Adshead, G., & Sarkar, S.P. (2007). Psychotherapy of psychopathic
disorders. In A. R. Felthous & H. Sass (Eds.), The International Handbook of
Psychopathic Offenders and the Law (pp. 449-456). Chichester, UK: Wiley.
Minzenberg, M.J., Poole, J. H., & Vinogradov, S. (2006). Adult social attachment
disturbance is related to childhood maltreatment and current symptoms of borderline
personality disorder. Journal of Nervous and Mental Disease, 194, 341-348.
Nørbech, P. C. B., Crittenden, P. M., & Hartmann, E. (2013). Self-protective
strategies, violence and psychopathy: Theory and a case study. Journal of Personality
Assessment, 95(6), 571-584.
O’Reilly, G. (2010). Attachment and sexual offending. Invited lecture at the 2nd
Biennial Meeting of the International Association for the Study of Attachment
(IASA), Aug. 30-Sept. 1, Cambridge, UK.
Renn, P. (2002). The link between childhood trauma and later violent offending:
The application of attachment theory in a probation setting. Attachment and Human
Development, 4, 294-317.
Ringer, F. & Crittenden, P.M. (2007). Eating disorders and attachment: The effects
of hidden family processes on eating disorders. European Eating Disorders Review, 15,
119-130.
Saradjian, J., Murphy, N., & McVey, D. (2010). Delivering integrated treatment
to people with personality disorder. In N. Murphy & D. McVey (Eds.), Treating
personality disorder: Creating robust services for people with complex mental health needs.
Hove, UK: Routledge.
Turton, P., McGauley, G., Marin-Avellan, L., & Hughes, P. (2001). The Adult
Attachment Interview: Rating and classification problems posed by non-normative
samples. Attachment and Human Development, 3, 284-303.
Van den Berg, A. & Oei, T.I. (2009). Attachment and psychopathy in forensic
patients. Mental Health Review Journal, 14, 3, 40-51.
Van Ijzendoorn, M.H., Feldbrugge, J.T.T.M., Derks, F.C.H., de Ruiter, C., Verhagen,
M.F., Philipse, M.W., van der Staak, C.P., & Riksen-Walraven, J.M. (1997).
Attachment representations of personality-disordered criminal offenders. American
Journal of Orthopsychiatry, 67, 449-459.
Warren, F., McGauley, G. A., Norton, K., Dolan, B., Preedy-Fayers, K., Pickering,
A., & Geddes, J. R. (2003). Review of treatments for severe personality disorder. Online
report 30/03. http://www.homeoffice.gov.uk/rds/pdfs2/rdsolr3003.pdf London:
Home Office.
Wilkinson, S.R. (2010). Another day older and deeper in therapy: Can the Dynamic
Maturational Model offer a way out? Clinical Child Psychology and Psychiatry, 15(3),
313-328.

126
Worley, K.O., Walsh, S., & Lewis, K. (2004). An examination of parenting
experiences in male perpetrators of domestic violence: a qualitative study. Psychology
and Psychotherapy: Theory, Research and Practice, 77, 35-54.

127
 Appendix 1 – Overview of Fens Unit
treatment programme

Individual
Timeline Group Work
Work

(15 weeks) DSPD Assessment Period

0 months Pd Awareness
3 months (0–6 months)
Human Relation-
6 months ships
(6–9 months)
9 months
12 months Affect Regulation
(1 year) Schema Focused Group (ARG)
18 months Cognitive Therapy Group (12–30 months)
Interpersonal (SFT) (total length of
24 months group is 11/2
Individual Groups (CIG) (12-42 months)
(2 years) years/18 months)
Therapy (0-60 months) (total length of
30 months (total length of group is 2 1/2 Addictive
group is years 30 months) Behaviour
36 months
5 years/60 Group (AB)
(3 years)
months) (36–48
months)
Inter-personal Offence Focused
(total length
42 months Relationships Therapy (OFT) of group is
(IRP) (36–60 months) 1 year/ 12
(42–51 months) (total length of month)
(total length of group is 2 years/24
48 months group is 9 months) months)
(4 years)
54 months

60 months Mens Group

(5 years) (54–60 months)

128
Chapter 5: The use of
DMM assessments in court
proceedings

Steve Farnfield, Ph.D., social worker, senior

lecturer and co-ordinator of the MSc in
Attachment Studies at the University of
Roehampton, UK

Abstract
Although courts and other decision making forums frequently ask
for an assessment of attachment the quality and evidence of these re-
ports is varied and sometimes based on little more than professional
opinion. This article presents a model for the assessment of paren-
ting and the use of attachment theory in the context of a family sys-
tems approach. It then explores the use of validated attachment as-
sessment procedures in the context of child maltreatment, fostering
and adoption. The argument is that for cases involving the removal
of children from birth parents only a forensic model of assessment
will do. This entails using validated procedures which are blind co-
ded by reliable raters. There follows the interpretation of the results
and their use in formulating a treatment or intervention plan. The
article makes reference to research on attachment based as compared
to attachment informed interventions.

Corresponding author Steve Farnfield, University of Roehampton,

UK
steve.farnfield@ntlworld.com

129
 Why is attachment important?
Attachment has been described as a mid-level evolutionary theory;
that is it employs empirical research to test aspects of Darwin’s grand
theory regarding the adaptation and survival of the human species
(Simpson & Belsky, 2008). Central to attachment theory is the
function of sex and caregiving: parents protect their children long
enough for the child to grow up and in turn have children of their
own thereby passing on parental genes.
Bowlby (1980) proposed that attachment in humans evolved
several million years ago and has remained fundamental unaltered.
He also proposed that to maximize survival different environmen-
tal conditions require both different patterns of caregiving and at-
tachment patterns to carers; hence the supposedly insecure Type A
and C varieties are functional for survival under certain conditions
(Bowlby, 1969).
Parents who are subject to court proceedings for maltreating or
neglecting their children have invariably suffered themselves and
may have inflicted further suffering on their offspring and other
people around them. From an attachment perspective the business
of assessment is to try and determine how parents respond to past
suffering, when they themselves were children, and how this informs
the way they bring up their own children. This invariably leads on
to questions regarding the ability of parents to alter their behaviour
within a realistic time period; i.e. while their children are still young
enough to benefit from the change.
Viewed somewhat cynically the business of assessments is an in-
dustry with maltreated children removed from parents and then
placed in foster care or adoption with people who either cannot have
children of their own or wish to care for other people’s. Attachment
and caregiving are just as important in the field of substitute care as
they are in child maltreatment and despite superficial differences the
determinants of assessment are fundamentally the same (Farnfield,
2008).

130
Behavioural systems
Attachment is less a personality trait, or style as some scholars like
to describe it, than it is a relational strategy; i.e. is likely to function
somewhat differently under different conditions and in different re-
lationships. Equally important is the concept of attachment as a be-
havioural system and the use of a systemic framework is an essential
step if we are to avoid confusing attachment behavior with the other
major behavioural systems which are depicted in figure 1.

Behavioural system Function

Attachment Protection of the self from danger

In adults pair bonding

Exploration Foraging – food, shelter

Developing skills
Mentalising; social co-operation ( Fonagy et al., 2002)
Recreation of self

Sex Procreation

Care giving Raising children & grand children – passing on our genes

Figure 1: Behavioural systems

In early childhood the attachment system functions to maintain

physical proximity, or under conditions where carers are neglectful
or actually dangerous, a minimum of psychological availability2.
A separate but related behavioural system is exploration, which in
small children we usually call play but, from a very young age, in-
cludes the development of mentalising (Fonagy, Gergely, Jurist, &
Target, 2002).
Put another way, what develops as playing with representations of
the self and other in adulthood (i.e. mentalising) has its roots in the
play of young children, crucially, while in the presence of an adult
who can themself mentalise (Allen, Fonagy, & Bateman, 2008). Just
as there are insecurities of attachment so there are insecurities of

2 See Landa & Duschinsky (2013) on this and the conceptual differences between
the ABCD and DMM approaches.

131
 exploration (Farnfield, 2014) although exploration as a behavioural
system has not been given extensive treatment by the DMM.
At puberty and beyond sex as a motivating factor enters the DMM.
This involves lust, a very primitive system requiring low or maybe no
mentalising (famously described by Sophocles as like being chained
to a maniac) and then attachment to a sexual partner which func-
tions to provide the basis for another crucial system: caregiving.
Whereas sex brings people together it is attachment that keeps
them together; the most common reason people give for not leav-
ing an abusive adult relationship is likely: ‘I don’t want to be alone.’
Should we live to a great age attachment and caregiving reverse
whereby frail elderly people become attached to their children.
A crucial question for a parenting assessment is how these differ-
ent systems impact on each other. Current knowledge is far from
complete on this subject but the following may be useful.

Attachment
Securely attached people are more likely to marry each other and
the combination of one partner in Type B married to a person who
is insecure has a stabilising effect on the relationship; i.e. mentalis-
ing is catching.Various combinations of insecurity are predicted to
increase the likelihood of specific problems. For example a marriage
between two people in Type A may function harmoniously (neither
seek deep emotional intimacy) but may become unstable when dee-
per co-operation is required when, for instance, they adopt a child.
Where both are in Type C enmeshment or dominance-submission
(Type C5 vs Type C6), this would include reoccurring domestic vio-
lence. Combinations of Types A and C might produce a push-pull
relationship with the person in C pursuing/demanding affection and
the one in Type A withdrawing (Crittenden, Partridge, & Claussen,
1991; Alexander, Teti, & Anderson, 2000; Schachner, Shaver, & Mi-
kulincer, 2003; Feeney, 2003).

132
Exploration
As noted above high levels of mentalising are strongly correlated
with secure attachment. This is not surprising as mentalising is an-
other way of describing the integrative aspects of information pro-
cessing (see below). Of interest to clinicians is evidence of integrative
mentalising in clients who are both insecurely attached on the AAI
and traumatised. In these situations the possibility that the person
will respond to appropriate treatment increases.
Attachment status in childhood is strongly associated with pat-
terns of play with secure children showing greater symbolic play.
They are also better at maintaining friendships (the Type B ability
to repair problems in relationships) than insecure children. As they
develop so children in the DMM Type A+ and C+ patterns show
corresponding insecurities of mentalising (Farnfield, 2014).

Sex
Whereas attachment and exploration have evolved, albeit with litt-
le significant changes in the last 2 million years, sexual behaviour
predates attachment and jams the neurological functions associated
with mentalising. That said the romantic lives of people in different
attachment patterns do seem different although this is likely to do
with the relational aspects of attachment, in particular trust in others
and comfort with intimacy than sex as a behavioural system (Hazan
& Shaver, 1987).

Caregiving
There has been considerable interest on how attachment strategies
are communicated from one generation to another. A classic study
by Fonagy and colleagues found that security of infant attachment
on the Strange Situation Procedure could be predicted by parental
AAIs even before the baby was born (Fonagy, Steele, & Steele, 1991;

133
 see also Hautamäki, Hautamäki, Neuvonen, & Maliniemi-Piispa-
nen, 2010). Parents who were secure on the AAI were significantly
more likely to have secure infants. This also holds good for foster care
of pre-school children; Dozier et al. (2001) found foster mothers se-
cure on the AAI were the only ones significantly likely to raise foster
children assessed as in Type B on the SSP. Only secure foster mothers
would do so that those in normative Type A still had foster children
assessed as D, Disorganized, on the SSP following at least 3 months
of foster care before the age of 24 months.
Work on the transmission of attachment produced an ap-
parent anomaly (termed the transmission gap): parent’s sensitivity
(what they do with their child) appears to be only weakly correlated
with security of child attachment. The mediating factor looks likely
to be how parents think about what they do; i.e. mentalising. The
neurological correlates for this hypothesis have been given impres-
sive support by Strathearn and colleagues with regard to openness
of secure mothers to their child’s distress compared with a shutting
down of empathy in mothers whose AAIs were assessed as Type A
(Strathearn et al., 2009).

A model for the comprehensive

assessment of parenting
Referrals to child protection agencies typically involve the omission
of caregiving (neglect, abandonment) or commission of harmful acts
(physical or sexual abuse). As well as forms of maltreatment to the
child they frequently contain information about the parents’ psycho-
social problems, such as substance abuse or domestic violence, which
are assumed to be the problem which has to be treated in order for
the children to remain safely with their parents.
The assumption that the substance abuse, for example, is the nub of
the problem is actually dubious and another approach is to start by
asking: what are the core dimensions of parenting? That is the dimen-
sions that are relevant to all parents and then ask what modifying

134
factors typically disrupt reasonable functioning of the core dimen-
sions. An attempt to answer this question resulted in the model de-
picted in figure 2.

Core dimensions of parenting

Childhood attachment system

1. The parent’s state of mind regarding their childhood attachments
2. Parent’s resolution of loss and trauma

The spousal system

3. Pair bonding & sexual partnership

Affiliative/ wider support system

4. Kinship, friends and wider support system including professionals

Care giving system – parenting

5. The meaning of the child to the parent

Modifiers to the core dimensions

Type 1: intra or inter personal

a). Mental illness
b). Learning disability
c). Substance abuse
d). Child sexual abuse
e). Domestic violence
f). Reconstituted families
g). Adolescent motherhood

Mentalising

Type 2: socio-political
E.g.
Cultural and sub cultural norms as to how children should be reared (e.g. smack-
ing)
Poverty, racism
Immigration status

Figure 2: Model for the core assessment of parenting (Farnfield, 2008)

135
 All parents carry the history of their own childhood experience (core
dimensions 1 and 2). This is all in the past and while the facts can-
not be changed the ability to sift what needs to be retained for future
self protection from what can be safely thrown away remains a life
long process (Crittenden, 2002). The impact of childhood trauma
on parenting has long been recognised and neatly captured in the
phrases ‘ghosts in the nursery’ (Fraiberg, Adelson, & Shapiro, 1975)
and more recently ‘shark music’ (Zanetti et al., 2011). When child-
ren get angry or are distressed and seek comfort this can elicit child
memories of abuse or neglect in the parent (shark music) so that the
parent acts in self protective rather than child protective ways (Crit-
tenden, 2008).
When anxiety heightens in the attachment relationship between
the child’s parents (the spousal system core dimension 3) so the risk
to the wellbeing of their children may intensify. In particular fears
that a spouse is being unfaithful or about to leave them may lead to
self protective behaviours in the parent which over ride caregiving;
for example domestic violence or abandoning the children to try and
regain the attention of their partner (Reder & Duncan, 2001).
A well documented feature of mal treating parents is their isola-
tion from family and other support networks (core dimension 4). In
a 4 month follow up of families assessed for social work intervention
as being in high need found no improvement in those who at the
time of referral had named less than 4 people (excluding profession-
als) to whom they could turn to for support (Gibbons et al., 1990).
Finally the meaning that a particular child holds for the parent
has been chosen as one crucial component of the care giving sys-
tem (core dimension 5). Whereas the parents of securely attached
children show enjoyment in their child and accept them as indi-
vidual people, insecure children are more likely to have parents who
are distancing or idealise them (neglecting parents) or else fear their
child will abandon them (enmeshed). Another group of parents have
very hostile representations of their child with a high risk of physical
abuse (Grey, 2010).
Whereas the core dimensions are applicable to all parents and par-
enting the modifiers are not central to the business of care giving
but impinge on the functioning of the core dimensions. These are

136
discussed more fully elsewhere (Farnfield, 2008) but to give some
brief examples: people who self medicate the effects of childhood
trauma (substance abuse) can actually parent less effectively when
sober (Reder, Duncan, & Lucey, 2003, 42); domestic violence and
reconstituted families exhibit problems best understood in the con-
text of the spousal and spousal/wider support systems respectively;
some teenage mothers struggling to parent do better when they cre-
ate more distance from their own mothers (conflicting enmeshed
relationships in dimensions 1 & 4) (Dukewitch, 1996).
An intra personal modifier is the ability of the parent to mentalise
(see above). This has obvious implications for parents who are of very
low intelligence and also where substance abuse is involved. From
case experience prescribed substances, such as methadone for heroin
withdrawing parents, dulls their affect with the result that although
they appear relatively able to mentalise on the AAI they cannot uti-
lize affective information when responding to their child.
The second group of modifiers are cultural and sub cultural norms
regarding how children should be brought up (e.g. smacking; dif-
ferential treatment of boys versus girls), environmental conditions
(poverty, dangerous neighbourhoods), immigration and racism.
From case experience shame appears a particularly powerful motiva-
tor where, for example, a woman has a baby out of marriage espe-
cially if the father is of the ‘wrong’ caste or colour within her own
culture. Isolation (core dimension 4) is also a problem for mothers
coming from cultures where childcare is shared by groups of biologi-
cally related women, which is actually the norm across time and cul-
tures (X), to a western society where both social supports are lacking
and the nuclear family structure is the norm.

137
 What can attachment assessments
tell us?
Crittenden defines attachment as having three equally important as-
pects:
1. A unique, enduring, and affectively charged relationship (e.g.,
with one’s mother, with one’s spouse)
2. A strategy for protecting oneself (of which there are three basic
strategies, Types A, B, and C, as identified by Ainsworth, and
many sub-strategies, as described by the DMM)
3. The pattern of information processing that underlies the
strategies. (Crittenden, 2008, 12)

Using the appropriate procedures assessments can tell us about each

of these and so inform some of the core dimensions of parenting in
the model outlined in the previous section.

Attachment to a specific person

Attachment to a particular person was the focus of the infant Strange
Situation Procedure (SSP; Ainsworth et al., 1978) originally desig-
ned for use with children aged 11 – 15 months and subsequently ex-
panded by the DMM-Preschool Assessment of Attachment so it can
be used up to about 60 months. The SSP remains the benchmark for
all other observational measures and, of particular interest, is actually
the only procedure available to assess a specific attachment relation-
ship (the basis of core dimension 1, above). No experimental proce-
dures coupled to observational measures exist to assess, for example,
an adult’s attachment to their spouse or partner. Representational
measures with children (below) do give some idea about attachment
to a particular parent but the results gained by using the SSP/PAA
are more valid (Farnfield, Hautamäki, Nørbech, & Sahhar, 2010).

138
A self protective strategy
The literature is vague concerning the point in development at
which children’s attachment to their attachment figures coalesces
into a more generalized strategy (number 2) for protecting the self
when feeling anxious in relational and social contexts. As well as
the observational SSP attachment strategies can be assessed by repre-
sentational measures using interviews which either ask a school age
child to tell stories about attachment themes, such as mother going
to hospital (the School Aged Assessment of attachment, SAA), or
interviews such as the Adult Attachment Interview (AAI – perfect
for core dimensions 1 and 2) (Farnfield, Hautamäki, Nørbech, &
Sahhar, 2010).
‘Representational measures’ refer to procedures which elicit the
mental representations people have about their attachment relation-
ships; literally the ability to re-present to the self and the interview-
er’s models of their attachment behaviour. All interviews do this and
in doing so tell us not what people actually do but how they think
about what they do. Representational measures can be used with
children as young as 37 months (Farnfield, 2014) but the available
DMM procedures begin with the SAA around 5 – 6 years. It is inter-
esting that as interviews become available so the use of observational
procedures declines and we have very little data on how speakers
assessed on the AAI as using a particular strategy actually behave in
real life.

Information processing
Representation opens the door to information processing. Bowlby
(1980) discussed this in terms of memory systems and defensive ex-
clusion. That is the process by which the mind excludes or distorts
information which, if it were brought to consciousness, would cause
a person intolerable mental pain.
Crittenden has expanded this process both in terms of her empha-
sis on cognitive and affective information and her treatment of the

139
 part different memory systems play in organizing strategies3. This is
conceptually complex but also an aspect of DMM assessments which
promises a great deal in terms of the depth of understanding we can
bring to the psycho-social functioning of particular individuals. Put
simply information processing refers to the intra-personal mecha-
nisms by which we make sense, or defend against, the many channels
of information that flood in from both the external environment and
from inside our minds and bodies. Whereas strategies are simpli-
fied models of behaviour (Type A or C or B) information processing
tells us how strategies are constructed and maintained and how they
function in Crittenden’s number 1 and 2 aspects above.
Information processing is not just about conscious cognitive men-
tal activity. In fact most of behaviour is affectively driven and occurs
outside consciousness (Damasio, 1994). However it has been taken
up in interesting ways by Fonagy and his colleagues in their treatment
of mentalising: the ability to differentiate between our own mental
states and those of other people (Allen, Fonagy, & Bateman, 2008).
Fonagy actually sees this as functional for human survival because it
has allowed us to co-operate in social groups and thus deploy more
effective strategies than those available to one person alone (Fonagy
et al., 2014). Although current work on mentalising can, at times,
seem biased towards cognition, explicit working memory and safety
(as noted above high functioning mentalising depends on secure at-
tachment), Fonagy and colleagues’ distortions of mentalising have
interesting overlaps with DMM accounts of information processing
in the deeply insecure Type A+ and C+ strategies.
In a classic paper (Crittenden, 2006), later turned into a book
(Crittenden, 2008), Crittenden asks the question why do abusing
parents do what they do? The answer is counterintuitive: to feel safer!
That is, they either act in self protective rather than child protective
ways or provide maladaptive responses to try and increase the safety
of their children.
A generalized example must suffice. When parental behaviour
meets the thresholds of the child protection agencies red lights start

3 Memory systems are not discussed here and the reader is referred to Crittenden &
Landini (2011).

140
coming up in the form of meetings with social workers. But some-
times nothing changes. More red lights are followed by a drastic step:
the children are removed to foster care. Now to the logical mind this
would indicate the final red light: if the parent wants to regain cus-
tody of their child they will do what is necessary to show the child
protection service they have changed. But in many cases this does
not happen. Why not?
To the parent the red lights do not signal stop but more danger.
Danger increases anxiety and so parents do more of what they have
been doing to protect themselves. This is in fact the context in which
many court assessments take place so that by the time the case is
heard the family situation looks hopeless: parents carry on drinking,
miss appointments, do not turn up to see their children and so forth.

Available assessments of attachment

and caregiving
The DMM assessments are given in figure 3 (see Farnfield, Hauta-
mäki, Nørbech, & Sahhar, 2010).

Procedure What it assesses

Infant CARE-Index Risk to the relationship; adult sensitivity
Toddler CARE-Index Risk to the relationship; adult sensitivity
Ainsworth Strange Situation Attachment of infant to specific attachment
procedure (SSP) figure (11 – 15 months)
Pre-school Assessment of Attachment of pre-school child to specific
Attachment (PAA) attachment figure (16 – 60 months)
School age assessment of Representation /state of mind
attachment (SAA)
Transition to Adulthood Attachment Representation /state of mind
Interview (TAAI)
Adult Attachment Interview (AAI) Representation /state of mind
Parents Interview Attachment strategy, parental reasoning &
couple functioning

Figure 3: DMM assessments of attachment & caregiving

141
 The CARE-Index offers a relatively weak assessment of children’s at-
tachment but a good indicator of risk to the relationship in terms of
the likely developmental trajectory of the child if things remain the
same. The Parents Interview is designed to assess both the spousal
and caregiving systems (core dimensions 3 & 5 in the model above).
Some other useful procedures are given in figure 4.

Parent sensitivity
• Marschak Interaction method (1960)
• Lausanne Trilogue Play Paradigm (Fivaz-Depeursinge & Corboz-Warnery, 1999)

Children’s representation of attachment

• Narrative story stems (XX; Farnfield, 2014)

Parents’ representation of child & caregiving

• Parent Development Interview (Slade, 2005)
• Meaning of the Child to the Parent Interview (Grey, 2010)

Figure 4: some other assessments

The Marschak Interaction Method (MIM) (1960) forms part of the

assessment for Theraplay. The carer is given a series of cards each sta-
ting a task or activity to be performed with the child. For example:
ADULT AND CHILD EACH TAKE A BOTTLE OF LOTION.
APPLY LOTION TO EACH OTHER.
Although there is a one minute separation the MIM is not coded
for child attachment but it is scored for aspects of caregiving and the
child’s responsiveness. The procedure is videotaped.
The MIM has a number of useful properties. It can be used in the
family home and the professional can switch on the camera and leave
the parent and child alone. Crucially the procedure induces intimacy
and touch: looking into each other’s eyes while rubbing lotion on the
other’s skin elicits both warmth and affection and defences against
the arousal associated with intimate contact.
The Lausanne Trilogue Play Paradigm (Fivaz-Depeursinge &
Corboz-Warnery, 1999) is of interest because unlike the CARE-In-
dex it involves the family triangle: mother, father and child play as
dyads (M+C; F+C; finally M+F excluding the child) and all together
(M+F+C). Of particular use to assessment is the way the adults ne-

142
gotiate the changes of activity (e.g. Mum has to withdraw from the
child and hand over to Dad), how they repair breaches in the inter-
action, and how the child manages the switch from close parental
attention to the parents interacting with each other and excluding
the child.
The established narrative story stem procedure is a doll play exer-
cise which involves the interviewer giving the child the beginning of
a story (the story stem) and asking her to “tell me and show me what
happens next.” The stories are video taped and coded using a number
of systems including the DMM based Child Attachment and Play
Assessment (CAPA) (Farnfield, 2014). Among the advantages of this
approach is that it neatly bridges the development transition from
play/showing to conversation based interviews and defensive exclu-
sion can be activated more easily than using interviews alone because
the child is invited to touch the dolls and enact scenarios.
A number of interviews are available to assess parent represen-
tations of caregiving and the meaning of a particular child to the
parent. As well as the Parents Interview the DMM based Meaning
of the Child to the Parent is particularly useful because it uses con-
structs for the meaning of the child drawn from the CARE-Index.
Thus what parents do, using the CARE-Index, can be compared with
representational models of caregiving (how they think about what
they do). Also useful is the Parent Development Interview (PDI)
which gives a scale for reflective functioning (RF), a key component
of mentalising: -1 (hostile repudiation) to 9 (extraordinary RF). A
score below 4 suggests response to intervention is likely to be slow.

Family triangulation
The previous sections emphasise that attachment and caregiving are
not static entities or abilities that ‘people have’ but are the products
of a dynamic social system. This is further illustrated when we con-
sider the impact of family triangulation on caregiving and children’s
attachment.
Attachment theory is sometimes criticized for being obsessed with

143
 the mother-child relationship to the exclusion of other relationships
and for being Eurocentric in that it assumes children grow up in the
2 parents 2 children nuclear family of 1950s middle class America.
With some mitigating circumstances (not least the difficulty of devis-
ing assessment procedures for complex extended family structures)
we have to plead guilty on both counts!
Outside the anthropological observations (De Loache & Gottlieb,
2000) understanding of attachment and extended family structures
is not advanced (Howes, 1999). More work has been done based
on family triangulation: typically the mother-father-child relation-
ship (see the LTP above). Triangulation is an established part of the
observational and analytical repertoire of systemic family therapists
and also formed the basis of an impressive systemic account of child
sexual abuse by the Great Ormond Street team in the 1980s (Ben-
tovim et al., 1988). A few limited observations are offered here based
on work by Marvin (2003).

Mother Father

Johnny

Figure 5: co-parenting in an adaptive family system (from Marvin,

2003)

Co-parenting in an adaptive family system (figure 4) entails the

parent couple thinking together about the child and caregiving is
supported by the spousal relationship so that it neither excludes the
child, as in a disengaged family system or enmeshed with permeable
boundaries between spousal and caregiving systems. Adaptive sys-
tems are expected to produce securely attached children.

144
Mother Father

Johnny

Figure 6: co-parenting in a disengaged family system (from Marvin,

2003)

In disengaged systems (figure 5) there is no room for the child be-

cause parents are too needy of each other or hostile and rejecting
towards the child. In this case the child is expected to mount varia-
tions on a Type A strategy such as compulsive caregiving (Type A3),
compliance (Type A4) or, when these strategies fail may withdraw
(Type A6) and/or show signs of depression (an awareness that no-
thing he can do will elicit anything more than rudimentary physical
care).

Mother
Johnny

Father

Figure 7: co-parenting in an enmeshed family system (from Marvin,

2003)

Enmeshed family systems offer a multiplicity of scenarios all of

which involve the child in the spousal system while, crucially, con-
cealing the true motives behind adult behaviour from the child so
she attributes more power and consequences to her own actions than
is actually case. Rather than role reversal one result is forms of spou-
sification (confusion over who is the psychological parent). In other
cases silence and deception may lead to extreme Type C5-6 strategies
found in some young people with eating disorders (Ringer & Critten-

145
 den, 2007). In the example in figure 6 Mother has a quasi-spousal rela-
tionship with son Johnny while treating her husband as another child.

A forensic model of assessment

The comprehensive model of assessment above can be used in all
kinds of settings and with greater or less adherence to formal pro-
cedures and coding protocols. In the context of court proceedings
which typically involve questions regarding whether or not biolo-
gical parents should be allowed to care for their children and if not
where and with whom the children should live, the demands on
accuracy and objectivity are considerably weightier. This requires a
forensic approach to assessment outlined in the bullet points below
(see Main, Hesse, & Hesse, 2011; Crittenden et al., 2013).
• Assessment procedures should be empirically validated.
• They must be administered by a professional with adequate
training to provide codable results.
• Coding should be done blind by coders certified reliable in the
particular procedure. This means that the coder knows nothing
about the case other than the ages of the people involved. This
reduces the inevitable bias which occurs once a professional
knows the history of the case and meets the family. It also means
that if there is a disagreement regarding the coding a second
opinion can be sought without necessitating a repeat procedure.
• Once the coder has assigned an attachment classification to the
procedure it can be discussed with the referrer.

Coders should provide more than an ABC+D or DMM classifica-

tion and, once this has been agreed, their opinion should take ac-
count of other information available. With representational proce-
dures in particular (e.g. narrative story stems or the AAI) the ways in
which a particular client processes information will be at the heart of
the formulation for treatment and intervention.

146
Ethics & transparency
Although all professionals subscribe to a code of practice working in
the court arena can introduce complex and sometimes competing
ethical pressures. For example:
• Do we really explain to the family what our assessments actually
measure?
• Is it possible to co-construct a court assessment with the family?
• Who will read what we write?
• Does the family get to see it first and have a chance to reply?
• Do they understand what we are talking about?
• What happens to all this information in the future?
• What follow up is there for parents if their children are
removed?
Psychologists, social workers and therapists see themselves as hel-
ping professionals dedicated to doing the best for their clients. In the
court setting the aim of the proceedings is to do what is best for the
child. But who is the client? The child? What about the parents? Or
for those working in state funded agencies the organisation that pays
our salaries? Or for free lance professionals the people who commis-
sioned the report in the first place? These are very real constraining
factors which a forensic approach to court assessments can help to
settle if just a little.
But there are other constraints; not just time and money to do a
good enough job but our own ability to face up to situations where
the outcome is not going to be good for anybody or maybe we have
exhausted our capacity to be helpful – too many red lights. To quote
a client of mine after an unsatisfactory encounter with his psychia-
trist: It was the failure of the doctor to comfort the patient with the truth.
Quite likely this ability eludes many of us and can’t be taught.

147
 Formulation
The use of attachment based assessments leads towards formulation
rather than diagnosis and prescription. This requires seeing the fa-
mily in terms of a dynamic system and it is at this point that profes-
sional judgement comes into play necessitating the integration of
information available from the history or other forms of assessment.
In other words we the professional have to mentalise!
This process cannot be manualised but it can be assisted by paying
attention to the family system and to how the players process infor-
mation regarding danger and sexual opportunity. Crucial to this are
the perceptions people have of danger and the impact this has on
their relationships.
For example: how does Mum react when Johnny wants comfort?
Why does she shrink away? What does Johnny do if Dad is at home?
How distorted is the meaning of Johnny to his parents? Is Johnny
safer with both parents together rather than with Dad alone? Which
behavioural system functions well and which needs attention?
Comprehensive assessments are complex and cannot be captured
in a case vignette. Understanding the impact that one behavioural
system has on another and how intrapersonal processes operate to
increase people’s perception of safety requires considerable experi-
ence as well as training. The following illustrates just a few aspects of
systemic and intra personal functioning. It is based on assessments
of 6 different families all of whom had adopted one or more children
and were experiencing severe problems in caring for them.
A common theme was a conflict between the parents’ state of
mind regarding their childhood attachment (core dimensions 1 & 2
assessed on the AAI) and the bond they formed with their adopted
child (core dimension 5 - meaning of the child to the parent). In all
cases one of the adoptive parents was in Type A2: this is the most
normative of the insecure patterns (Type A2 is notoriously difficult to
differentiate from B2 when coding AAIs) and, based on one DMM
study, the dominant pattern for adoptive parents (Farnfield, 2012).
The breakdowns between these adoptive parents and their child had
a common thread: anger in the child challenged inhibition of anger

148
in the adults. These traumatised and distressed children challenged
the parental norms concerning how children should behave with the
result that their representations of the child were angry and punitive
(more like Type C5 attachment).

Ports of entry
In attachment terms the central question for treatment is: what will
help each member of the family feel safer than they do now? I.e. can we
turn on some amber or even a green light? Recommendations for
treatment should be made with this question in mind.
Selection of treatment can usefully focus on both behavioural sys-
tems and the intra personal functioning of individuals, especially
the effects of attachment trauma. Regarding intra personal function-
ing Crittenden has proposed an information processing approach
to treatment based on the functioning of memory systems which
can be uncovered using representational assessments such as the AAI
(Crittenden, Landini, & Claussen, 2001; Farnfield, 2014). A behav-
ioural systems approach invites us to identify which system offers the
best chance of change following intervention.
• The caregiving system – e.g. Mum & Johnny?
• The parent attachment system – Mum or Dad’s state of mind re
childhood attachment?
• The spousal system – Mum & Dad together?
• The wider support system?

149
 Attachment based vs attachment
informed interventions
The majority, maybe all established therapeutic modalities are an-
chored in the principle of the therapist as a secure base for their
clients. While not attachment figures in the same way as parents
are to children or partners are to adults, all therapists seek to offer
a safe space in which their clients can mentalise (Allen, Fonagy, &
Bateman, 2008).
That said therapies vary greatly in the degree to which they use at-
tachment theory and research and the extent to which they claim to
be rendering their clients more secure. Finding a conceptually satis-
fying route through the maze of attachment therapies is difficult and
Obegi and Berant (2009) make the useful distinction between in-
terventions which are attachment informed and those which are at-
tachment based. Attachment informed interventions use attachment
theory and research but rely on established therapeutic modalities
in terms of approach and technique. In contrast attachment based
interventions make explicit use of attachment theory and research
together with pre/post validated attachment assessments.
Figure 7 gives a brief summary of results from a recent review
(Farnfield, 2014). The greatest number of both types can be found in
treatments designed to improve the parent-child relationship. These
include the most robust attachment based interventions, such as
Video-feedback Intervention to promote Positive Parenting (VIPP;
Juffer, Bakermans-Kranenburg, & van IJzendoorn, 2014) and the
Circle of Security, which employs pre/post SSP (Zanetti et al., 2011).

150
 Intervention Attachment based Attachment informed
Parent-child interven- Many Many
tions/psychotherapy E.g. VIPP; Circle Security; E.g. Theraplay; VIG; Marte
Watch Wait Wonder; ABC; Mayo; Webster-Stratton
Sunderland Infant Pro-
gramme
Individual Adult therapy Limited Many
Individual child therapy None Many
PTSD children CBT; EMDR Various
Family therapy None Some

Figure 7: Attachment based vs attachment informed interventions

(Farnfield, 2014)

The literature gives strong support for video-feedback involving

parent and their own child rather than parent training videos using
strangers (e.g.Webster-Stratton, Rinaldi, & Reid, 2011). Changing
adult parent sensitivity (what they do) appears easier than increasing
children’s attachment security and an argument has been mounted
that short (less than 16 sessions) interventions are more effective
than long term (Juffer, Bakermans-Kranenburg, & van IJzendoorn,
2014).
While good results have been reported using EMDR and CBT to
treat PTSD in children it is interesting that there is no data on the
effect of individual child therapy on children’s attachment. Also of
note is that despite the inter-personal strategic function of attach-
ment there are no attachment based family therapy interventions.

151
 Final observations
Attachment is not a theory of everything and taking a system per-
spective helps separate attachment from other systems so that we can
ask how each system reacts to another. Nor can the DMM explain
everything. What it does bring is the following:
• A conceptual framework which makes sense to professionals
working with people who have experienced extremes of
suffering. Entering the DMM stage we feel we know these
people and have met them before.
• A model which is sensitive to differences between and within
cultures.
• A set of tools with which to assess attachment behaviour at all
stages of development using the DMM conceptual wheel.
• Information processing.

It is the last, information processing that promises the most. The

DMM has closed the work begun by Bowlby and Ainsworth which
aimed to construct a typology of attachment behavior. Crittenden
responded to Bowlby’s celebrated comment to Ainsworth that they
should call the observed infant behaviours in the Strange Situation
Procedure ABC until they had a better understanding of what they
meant. The next step is to deepen Crittenden’s work, also begun by
Bowlby, on information processing. This is the how and the why
behind the ABC of behaviour. How do people perceive danger and
what is the function of their behaviour? Coupled to work in the
neurosciences we may start to find we have a better idea of the right
treatment for a particular family. One based on formulations that
reveal what goes on behind the mask of ABC.

152
References
Ainsworth, M.D., Blehar, M.C., Waters, E., & Wall, S. (1978). Patterns of
attachment: A psychological study of the Strange Situation. New Jersey: Erlbaum.
Alexander, P.C., Teti, L., & Anderson, C.L. (2000). Child abuse history and role
reversal in parenting. Child Abuse and Neglect, 24, 829-838.
Allen. J.G., Fonagy, P., & Bateman, J.G. (2008). Mentalizing in clinical practice.
Washington D.C.: American Psychiatric Publishing Inc.
Bentovim, A., Elton, A., Hildebrand, J., Tranter, M., & Vizard, E. (Eds.) (1988).
Sexual child abuse within the family. London: Wright.
Bowlby, J. (1980). Attachment and loss: Loss, sadness and depression. Vol. 3. New York:
Basic Books.
Crittenden, P.M. (2002). Attachment, information processing, and psychiatric
disorder. World Psychiatry 1(2), 72-75.
Crittenden, P.M. (2006). Why do inadequate parents do what they do? In O.
Mayseless (Ed.), Parenting representations: Theory, research, and clinical implications
(pp. 388-433). Cambridge: Cambridge University Press.
Crittenden, P.M. (2008). Raising parents: Attachment, parenting and child safety.
Cullompton, Devon UK: Willan.
Crittenden, P. M., Farnfield, S., Landini, A., & Grey, B. (2013). Assessing attachment
for family court decision-making: A forensic protocol for empirically-based evidence
regarding attachment. Journal of Forensic Practice, 15(4).
Crittenden, P.M., & Landini, A. (2011). Assessing adult attachment: A dynamic-
maturational approach to discourse analysis. New York: Norton.
Crittenden, P.M., Landini, A., & Claussen, A.H. (2001). A dynamic-maturational
approach to treatment of maltreated children. In J.N. Hughes, A.M. La Greca, &
J.C. Conoley (Eds.), Handbook of psychological services for children and adolescents (pp.
373-398). New York: Oxford University Press.
Crittenden, P.M., Partridge, M.F., & Claussen, A. H. (1991). Family patterns
of relationship in normative and dysfunctional families. Development and
Psychopathology, 3, 491-512.
Damasio, A. (1994). Descartes’ error: emotion, reason, and the human brain. New York:
Avon.
De Loache, J. & Gottlieb, A. (Eds.) (2000). A world of babies: imagined childcare
guides for seven societies, Cambridge: Cambridge University Press.

153
 Dozier, M., Stovall, K.C., Albus, K.E., & Bates, B. (2001). Attachment for infants in
foster care: the role of caregiver state of mind. Child Development, 72, 5, 1467-1477.
Farnfield, S. (2012). Bindung und Anpassung bei Ersatzeltern. In M. Stokowy & N.
Sahhar (Ed.), Bindung und Gefahr. Das Dynamische Reifungsmodell von Bindung und
Anpassung (pp. 163-186). Giessen: Psychosozial-Verlag.
Farnfield, S., Hautamäki, A., Nørbech, P., & Sahhar, N. (2010). DMM assessments
of attachment and adaptation: Procedures, validity and utility. Clinical Child
Psychology and Psychiatry, 15(3), 313-328.
Farnfield, S. & Holmes, P. (2014). Introduction. In P. Holmes & S. Farnfield (Eds.),
The Routledge Handbook to Attachment: Intervention. London: Routledge.
Feeney, J.A. (2003). The systemic nature of couple relationships: an attachment
perspective. In P. Erdman & T. Caffery (Eds.), Attachment and family systems:
conceptual, empirical, and therapeutic relatedness (pp. 139-164). Hove, UK: Brunner-
Routledge.
Fivaz-Depeursinge, E. & Corboz-Warnery, A. (1999). The primary triangle: a
developmental systems view of mothers, fathers, and infants. New York: Basic Books.
Fonagy, P., Steele, H., & Steele, M. (1991). Maternal representations of attachment
during pregnancy predict the organization of infant-mother attachment at one year of
age. Child Development, 62, 891-905.
Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation,
mentalization and the development of the self. New York, NY: Other Press.
Fonagy, P., Lorenzini, N.,Campbell, C., & Luyten, P. (2014). Why are we interested
in attachments? In P. Holmes & S. Farnfield (Eds.), The Routledge Handbook to
Attachment: Assessment. London: Routledge.
Fraiberg, S., Adelson, E. & Shapiro, V. (1975). Ghosts in the nursery: A
psychoanalytic approach to the problems of impaired infant-mother relationships.
Journal of American Academy of Child Psychiatry. 14, 387-421.
Gibbons, J. with Thorpe, S. and Wilkinson, P. (1990). Family support and prevention:
Studies in local areas. National Institute for Social Work, London, HMSO.
Grey, B. (2010).The meaning of the child in parenting interviews: a comparative study
using the Parent Development Interview and the CARE-Index. Poster and seminar
presented to the 2nd Biennial Conference of the International Association for the
Study of Attachment, Cambridge, August 29 - Sept. 1, 2010.
Hazan, C. & Shaver, P.R. (1987). Romantic love conceptualized as an attachment
process. Journal of Personality and Social Psychology, 52, 511-524.
Hautamäki, A., Hautamäki, L., Neuvonen, L., & Maliniemi-Piispanen, S.
(2010). Transmission of attachment across three generations. European Journal of
Developmental Psychology, 7(5), 618-634.

154
Howes, C. (1999). Attachment relationships in the context of multiple caregivers. In
J. Cassidy & P. Shaver (Eds.), Handbook of attachment: Theory, research and clinical
applications (pp. 671-687). New York: The Guilford Press.
Juffer, F., Bakermans-Kranenburg, M.J., & van IJzendoorn, M.H. (2014).
Attachment-based interventions: Sensitive parenting is the key to positive parent-
child relationships. In P. Holmes & S. Farnfield (Eds.), The Routledge Handbook of
Attachment: Implications and Intervention. London: Routledge.
Landa, S. & Duschinsky, R. (2013). Letters from Ainsworth: Contesting the
‘organization’ of attachment. Journal of the Canadian Academy of Child and Adolescent
Psychiatry, 22(2), 172 – 177.
Main, M., Hesse, E., & Hesse, S. (2011). Attachment theory and research: Overview
with suggested applications to child custody. Family Court Review, Special issue on
attachment, separation, and divorce: Forging coherent understandings for family law,
49, 3, 426-463.
Marschak, M. (1960). A method for evaluating child-parent interactions under
controlled conditions. Journal of Genetic Psychology, 97, 3-22.
Marvin, R.S. (2003). Implications of attachment research for the field of family
therapy. In P. Erdman & T. Caffery (Eds.), Attachment and family systems: Conceptual,
empirical, and therapeutic relatedness (pp. 3-30). Hove, UK: Brunner-Routledge.
Obegi, J.H. & Berant, E. (2009). Introduction. In J. H. Obegi & E. Beran (Eds.),
Attachment theory and research in clinical work with adult (pp. 1 – 14). New York:
Guilford Press.
Reder, P. & Duncan, S. (2001). Abusive relationships, care and control conflicts and
insecure attachments. Child Abuse Review, 10 (6), 411-427.
Reder, P., Duncan, S., & Lucey, C. (2003). Studies in the assessment of parenting.
London: Routledge.
Ringer, F. & Crittenden, P.M. (2007). Eating disorders and attachment: The effects of
hidden processes on eating disorders. European Eating Disorders Review, 15, 119-130.
Schachner, D.A., Shaver, P.R., & Mikulincer, M. (2003). Adult attachment theory,
psychodynamics and couple relationships: an overview. In S.M. Johnson & V.E.
Whiffen (Eds.), Attachment processes in couple and family therapy (pp. 18-42).New
York: The Guilford Press.
Shah, P. E., Fonagy, P., & Strathearn, L. (2010). Is attachment transmitted across
generations? The plot thickens. Clinical Child Psychology and Psychiatry, 15(3), 329-
346.
Slade, A. (2005). Parental reflective functioning: An introduction. Attachment and
Human Development, 7, 3, 269 – 281.

155
 Strathearn, L., Fonagy, P., Amico, J. A., & Montague, P. R. (2009). Adult
attachment predicts mother’s brain and oxytocin response to infant cues.
Neuropsychopharmacology, 34(13), 2655-2666.
Webster-Stratton, C., Rinaldi, J., & Reid, J. M. (2011). Long-term outcomes of
Incredible Years parenting program: Predictors of adolescent adjustment. Child and
Adolescent Mental Health, 16(1), 38-46.
Zanetti, C.A., Powell, B., Cooper, G., & Hoffman, K. (2011). The circle of security
intervention: Using the therapeutic relationship to ameliorate attachment security in
disorganized dyads. In J. Solomon & C. George (Eds.), Disorganized attachment and
caregiving (pp. 318 – 342). New York: Guilford Press.

156
View publication stats