Psychodynamics, attachment and psychosis, by Allison Summers

Attachment theory


Attachment theory originates with the psychoanalyst, John Bowlby, who defined attachment as an affectional bond with a 'differentiated and preferred individual' or attachment figure. Attachment figures are seen as providing a safe haven in times of distress and threat, as well as a secure base from which to explore the world.

Attachment bonds develop in infancy, when they are thought to have an evolutionary survival value through ensuring that the caregiver remains close to the vulnerable infant. When caregivers are able to offer a good enough response to an infant's needs, a secure attachment develops whereas in less favourable circumstances, various forms and degrees of insecurity are possible. Attachment patterns in early life affect the individual's later attachment relationships and the attachment system remains important throughout the life cycle.


The relationship between psychodynamic and attachment approaches

Attachment theory developed out of a branch of psychoanalysis which regards human beings as having a primary instinctual drive to relate to others. However over several decades the attachment and psychodynamic fields developed along divergent paths, with work on attachment focusing on empirical research and cognitive aspects.

More recently there has been recognition of the extensive common ground between the two approaches. In addition, attachment research has provided confirmation of many psychodynamic theories about the way psychosis develops and persists.

There are also areas of difference between attachment and psychodynamic thinking. It may be that bringing together ideas from the two fields could offer new possibilities for development of our understanding of psychosis and of more effective therapies.

Different names for similar concepts

Often the psychodynamic and attachment fields have different names for similar concepts. For example the important psychodynamic concept of containment, refers to how a relationship may allow emotion to be tolerated, digested, and become thinkable rather than avoided. This seems to have much in common with attachment ideas about how a secure attachment enables emotion to be reflected on (or, in attachment terms, mentalised).

Attachment theory categorises attachment relationships according to the degree and form of insecurity within them. Some of the more extreme defensive constellations of psychodynamic theory can be seen as similar to more extreme patterns of attachment insecurity, for example schizoid patterns may be likened to avoidant attachment, histrionic to hyperactivating and borderline personality features to disorganised attachment.

Perspectives on the development of psychosis

Attachment theory has most in common with the psychodynamic approaches which are described as relational. Like attachment theory, these theories are based on the idea that early relationships shape our subsequent experience of ourselves and other people, and the emotional quality of relationships.

Like attachment theories these psychodynamic theories see psychosis as a response to unmanageable negative affect. They hold that adversity in early relationships can affect mental development in a way which increases vulnerability to psychosis. Attachment theory and research identify a number of specific ways in which this can happen, including by affecting our abilities to regulate emotion and to reflect on our own and others' thoughts and feelings (ie to mentalise).

Psychodynamic and attachment practitioners both use approaches to understanding an individual that link life history with later experience and behavior. Psychodynamic approaches differ in their attention to the role of unconscious emotion and defences and in drawing on a wider range of clues to these for example clues in language, dreams, psychotic experiences, and in practitioners’ responses to their clients (countertransference).


Therapies based on attachment theory and research aim to use techniques derived from this to enhance the security of the client's attachment. Some new varieties of therapy are being developed with this aim, often combined with cognitive approaches.

Relational forms of psychodynamic therapy could be seen in some ways as attachment-based therapies, even though not explicitly calling themselves this. They certainly have many features likely to increase attachment security, including, for example, the focus on clients' moment to moment experience with the therapist, and the way in which a skilled therapist's responses are attuned to the client's emotional state and capacities. More supportive forms of psychodynamic therapy may have additional features likely to enhance attachment, for example interventions that help mentalising. In the longer therapies which are more likely with psychodynamic than cognitive approaches, a relatively secure attachment relationship with a therapist may perhaps allow a person to develop new capacities and new ways of experiencing the world.

There is still a lot of uncertainty however around what it is that enables any helpful therapy to achieve its effects. There is also uncertainty about what approaches are likely to be most helpful for any particular individual.

It seems almost certain that aspects of therapists’ own attachment styles and related features will have a significant contribution to therapeutic relationships; their capacity to be flexible in their attachment style is probably also of considerable importance in sustaining the therapeutic relationship.

Despite the uncertainties, many believe that attachment theory and research have a useful contribution to make to the ongoing understanding and development of therapy for individuals who experience psychosis. It seems important also not to overlook the role of attachment in existing approaches which are named psychodynamic rather than attachment therapy.

Further reading

Burke E, Danquah A, Berry K (2015) Clinical Psychology and Psychotherapy A Qualitative Exploration of the Use of Attachment Theory in Adult Psychological Therapy. Clin. Psychology. Psychotherapy. Published online in Wiley Online Library ( DOI: 10.1002/cpp.1943, see abstract

Harder S. (2014) Attachment in schizophrenia: implications for research, prevention and treatment. Schizophrenia Bulletin, 40,6, 1189-93. See full text

Schwannauer, M. and Gumley, A (2014) Attachment theory and psychosis. In: Attachment theory in adult mental health. Eds. A Danquah and K Berry. Abingdon: Routledge. See Book on amazon




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