The Integration of the Adult Attachment Interview (AAI) and the “Three Pillar” Method of Healing Attachment Disturbances in Adults; via Integrative Attachment Therapy (IAT) Zack Bein, Psy.D.

The Adult Attachment Interview (AAI) provides valuable information about the patient’s childhood experiences that were problematic for the development of attachment security. This chapter will review the AAI and illustrate its usefulness to the therapist practicing Integrative Attachment Therapy (IAT). The results of the assessment are obtained by submitting the recording of the interview to an approved transcriber and having the transcription scored by a reliable AAI coder. The coder may provide the therapist with a thorough and detailed clinical report of the patient’s raw data and results. In this case, the therapist can synthesize the quantified research into an accessible, understandable, and shortened summary of the raw data report. Some therapists choose to share their synthesized and shortened summary and review it with the patient. Some therapists will discuss and process this summary in verbal form. However, the raw data and any extensive and thorough clinical report written by the coder should never be distributed to the individual patient, for a number of clinical and ethical reasons.  

Integrative Attachment Therapy, based on the Three Pillars of attachment repair, which includes the Ideal Parent Figure (IPF – 3^rd Pillar) method (Brown & Elliott, 2016), integrates the findings from the AAI into treatment planning.  One way this is done is by noting if the adult as a child had parents who pressured them to achieve, were neglecting, rejecting, over-involving, or loving. One can also see if the patient is currently idealizing a parent, angry with a parent, or derogating of attachment experiences. And, of course, noting the official AAI classification of the patient directly informs the secure imagery created in Integrative Attachment Therapy.

To fully understand the theoretical and practical underpinnings of IAT and the Three Pillars model, one must begin with the pioneer of attachment theory, John Bowlby. According to Bowlby, an attachment-focused therapist aims to provide a “secure base” from which the patient can verbally explore in psychotherapy the vast array of their intrapsychic and external experiences (Bowlby, 1988). This position has been widely accepted in the field.  However, attachment research has yielded the vital information that one’s formation of the “Internal Working Model,” (IWM) of attachment, as Bowlby (1988) termed it, is established between 12 and 20 months of age. The narrative function of the brain in humans, however, does not become fully developed until the beginning of the fourth year of life (Pillemer & White, 1989). Therefore, it is perhaps unreasonable to assume that the adult population presenting with consistent relational issues, rooted in their insecure model of attachment, will be able to verbally explain, describe, or even recall the quality of the events between 10 months and 2 years. Since behavioral memory is the primary memory system in the first years of life, these attachment-related disturbances in adults are likely to be expressed by re-enactments of unhealthy patterns in relationships and the perceived inability to disengage with such behaviors. The Internal Working Model (IWM) is well in-place before our narrative verbal memory and skill has developed. 

In addition to the awareness that Bowlby brought to the development of the IWM, he equally stressed the importance of using the therapist as the “secure base” to actually change the patient’s afflictive IWM to one that provides them with a new resource and new understanding of who they are and how they fit into the world. Are they lovable? Do they have needs that are important? Is it safe to ask to get those needs met? And can those needs even be met in this lifetime? Through consistent and reliable psychotherapy, one begins to unlearn the old model and adopt a new model.

 Building upon this knowledge, Brown and Elliott (2016) developed the Three Pillars psychotherapeutic model. This model was intended to offer a comprehensive way to resolve the structural core of attachment insecurity by restructuring and re-mapping the Internal Working Model of attachment in patients using imagined ideal parent figures (3^rd pillar), guided by the five qualities that create secure attachment, as well as any “positive opposites” identified in the AAI. Often by this process alone, the patient begins strengthening several capacities that were developmentally impeded by the insecure upbringing (Elliott, 2021). 

Two specific capacities that are often impaired in children with insecure attachment styles are collaborative abilities and metacognitive functioning. There are many ways in which therapists can aid in the development of collaboration (1^st pillar) and metacognition (2^rd pillar) with adult patients. For the sake of this chapter, we will focus mainly on the 1^st and 3rd pillars. Addressing the first and third pillar includes exploration and mentalization components, and promote the development of metacognitive capacity by encouraging patients to examine the mind-states and behaviors of the ideal parents and how those mind-states and behaviors lead to a different experience for the patient-as-child.  They also learn collaborative abilities as they work together with their ideal parents and the therapist to create and maintain the conditions that promote security via the imagery.

 Over time, the old problematic patterns that were steeped in the non-verbal and unconscious Internal Working Model come into awareness. Often, some sadness or grief arises in concurrence with that insight. While the patient is feeling the possibility of safe and attuned parents, they may feel sadness or grief that this is perhaps the first time that they have experienced and felt this quality of care. It is important to be able to hold both this grief experience and the continuation of the experience of the secure IPF imagery.  When grief arises in the context of the imagery, the IAT therapist suggests that the ideal parents recognize the grief and respond in ways that feel just right to the patient-as-child. When the imagery session is brought to a close, then the therapist and patient might together affirm and explore the grief that arose. 

During the AAI, the subject is asked 20 questions, with a number of follow-ups. One can get trained to administer the AAI. Dr. Howard Steele made a short 45-minute video available to clinicians who are interested in administering the AAI. However, to become a reliable coder and scorer and interpreter of results, one must complete a years-long training, consisting of scoring over 30 AAIs and achieving at least 80% concurrent reliability with the creators of the assessment. A reliable coder can be located by emailing ngbreliability@gmail.com.  

As stated for years, the AAI should be administered by a trained and licensed clinician. It is a psychological assessment, empirically validated, and requires a baseline level of clinical competence to administer an AAI. After some general questions about the upbringing, the subject is asked to give five words or phrases that describe the early child relationship between them and mother, and then with father.  Just from this question alone, significant information is given to the IAT therapist. If the interviewee states that their mother was “absent” and “neglectful,” and they have memories to support that assertion, we will suggest the “positive opposites” of those words – “present” and “attentive,” in the co-creation of the Ideal Parent Figure imagery in the subsequent sessions. If the patient gives only very positive words, like “loving,” “caring,” and “supportive,” and then does not have adequate memories to support that picture, then the clinician should be aware that there is possibly some idealization occurring which may lead to a dismissing classification which only further informs the IPF work. 

Subsequent to the AAI questions that ask for descriptors of early caregiver relationships, there are a number of questions about separation, about what the patient would do when they got upset, hurt, or ill as a child, if they ever felt rejected from their parents, or threatened.  The subject is asked if they underwent any physical or sexual abuse, and if they lost anyone very close to them in childhood, as we know that loss and trauma affect one’s attachment outlook. There are questions to assess the changes in the relationships in adolescence, and finally to what the relationship is like today. 

The AAI takes about 45 to 60 minutes to administer.  For clinical purposes, the AAI should be administered by the clinician or therapist that is going to be seeing the patient for therapy. Unlike for research purposes, it is actually very important for the therapist to get a “feel” for the patient during the AAI. It also allows an opportunity for the initial establishment for rapport, as the IAT therapist comes from a highly collaborative framework. When the clinician meets with the patient the following session to discuss the results of the AAI, there will already be a level of comfortability and the sense of the collaborative effort on behalf of the clinician will be apparent. 

After the interview is complete and recorded, it is then transcribed and scored by a reliable scorer through the AAI Institute as described earlier. And herein lies the confusion and need for clarity on how the AAI results are to be shared clinically. As the AAI is a research instrument that was normed using group means, there are going to be some questions about validity and reliability and whether one can take the group research design and assume the same conclusions even though the conditions are completely different when using the AAI on a one-on-one basis. A clinician or psychologist who is fully trained in all of these areas is going to recognize that and use the AAI results accordingly. There is a 30% or so likelihood that another coder deemed “reliable” by the Institute would arrive at different conclusions. Thus, these results are not to be deified, but rather should be seen as an opportunity for both clinician and patient to discuss it together and see what might be useful as a collaborative focus of treatment. Individuals who lack clinical or research training, who claim to “facilitate” AAIs and “IPF”, often provide their students with the raw data AAI reports, which contain clinical language that could be misconstrued and detrimental to the student.  Sharing the raw data report has created a climate where patients whom do not receive the raw data report, they think they are not getting their full results. In fact, they never should have received the raw data in the first place.

Whether the coder decides to give the raw data to the clinician or not, Verbal feedback only is to be given to the patient during their next session. If the patient explicitly asks for a report, then the clinician should take the raw data and synthesize it into an understandable and palatable summary of what and how the AAI assessed, and a small discussion about how the coder arrived at their results. The raw data and report are not to be shown to the patient for ethical reasons and to preserve the integrity of the test. Regarding the ethical considerations, imagine for a moment, coming for treatment in the most vulnerable place you have ever been. You have 1 hour of someone strange firing personal question after personal question about your life. Then, they tell you that you will meet again in a week to talk about your “results.” When meeting for the 2^nd time with this stranger, they quantify on a likert scale the degree to which your primary caregivers were loving or present, they inform you that regardless of whatever work you have done, that you have unresolved abuse. And you see a graph full of numbers quantifying your childhood experience. While some may find this thrilling (people who would score in the F, or secure, region), most who report for this assessment find this retraumatizing and confusing.

It is widely in agreement amongst the top researchers in the attachment field; including, Dr Miriam Steele, Dr Howard Steele, and Dr Erik Hesse, that the ideal way to provide feedback if at all to the individual AAI recipient would be in verbal form. So, the fact that there is some confusion on what the AAI is and how it is used clinically comes as little to no surprise. Nonetheless, this chapter aims to dispel any of the confusion and lack of clarity around this empirically derived research tool, and how one is to use it in their clinical practice in a way that is helpful, and especially, ethical.

The AAI is a research tool that is derived from group means, and not intended for one-on-one usage nor was it intended that feedback would be given on a one-on-one basis. Probable childhood experiences, probable states of mind with regard to attachment, and probable attachment classifications are verbally discussed with the client.  Using the evidence from the interview, the therapist and patient will collaborate (1st pillar) to co-create the imaginal and secure imagery of the patient’s own unique ideal parent figures, using this idea of the “positive opposites” and the five qualities that we know allow for secure attachment in children.

The AAI transcript and coding provide the therapist with information about the patient’s particular experiences that were problematic for the development of attachment security. The therapist takes note of this information, and lets it inform the application of the IPF imagery process.  For example, with a patient who had little sense of safety with caregivers as a child, the therapist emphasizes how the ideal parent is completely non-threatening and supportive of feelings of safety and protection. The patient is encouraged to imagine all the ways the parents could be, all the things they could say, all the things they could do, all the ways they could be with them, that would help them to feel safe, even just marginally at first, including in the body. And then leave some space for the patient to imagine, and then simply check in. “And if feels comfortable to give some words to what you’re imagining, you can do so.” If the patent’s response is aligned with the idea of safety and the client is imagining things the parents might say and the ways they might be to support the sense of safety, then the therapist could amplify or emphasize that. “Yes, really feel what that’s like to know at a deep level that you are completely protected.”

If the patient simply cannot imagine anything that would give them a sense of safety, the therapist will normalize the difficulty, and have them notice that the ideal parents see how difficult it is. And they see that difficulty as the most normal and natural thing in the world at first. And if the patient needs all of the time in the world to get comfortable with these ideal parents, that is totally fine with them. If there is a positive response from the patient, the therapist marks the affect. “Really take that in.  Really feel that permission, and flexibility.” And continues to check-in with what the patient is imagining, marking and amplifying when they spontaneously bring up attachment promoting qualities, and helping and encouraging and reframing when they are having difficulty. In this way, collaboratively, the patient and therapist build the imagery with the goal of eventually internalizing those qualities of secure attachment in their mind and in their body and having the patient experience many positive opposites found on the AAI, effectively restructuring the Internal Working Model of attachment.

There are a number of sources that one can use to begin to identify and define the Ideal Parent Figures (IPFs). The first source is the above-mentioned five qualities that promote secure attachment. Before even asking the client to imagine an ideal figure, some therapists choose to go over the five qualities (presented in Brown & Elliott, 2016, pp. 288-292). 

1. Safety and protection
2. Attunement to behavior and emotion
3. Emotional soothing
4. Expressing delight in the very being of the child
5. Encouraging the individual exploration of the child

The clinician discusses each of the qualities in detail, asking for and exploring examples of what each of those qualities might look like in a parent, and asking the patient what their experience is of any of the above qualities. Once discussing the five qualities, we begin to talk about the ideal “figures.” This is a part of the treatment that can have a great deal of variability in response. For some patients, they are excited to imagine these figures in detail. They are probably visual learners and creatively inclined. Then, there are those who are less visually inclined, who come into the process with a preconceived notion that they will not be able to imagine a figure.  These patients require more assistance in the beginning, and reminders that some difficulty in the beginning it perfectly natural. “Yes, notice that your IPFs can tell, even though you can’t see them, you can feel like they totally understand why this would take you a while and they put no pressure on you whatsoever.” If the patient is having trouble imagining secure and safe figures, it can often be helpful to encourage them to think about characters in movies or books, or teachers, that provide them a feeling of security. 

Another source for IPF qualities is called the “positive opposites.” Here we directly use the AAI to look for negative or difficult caregiving qualities or experiences, and make sure that the IPFs contain the “positive opposite” qualities. Simply put, if actual mom was too absent, then for ideal mom, there is extra emphasis on just how present she is. If actual dad was overinvolved, then ideal dad is more spacious and more encouraging of autonomy. Between these two sources, both obtained by the AAI, there are regularly enough secure qualities for the patient and therapist to explore within the first few imagery sessions.

A first, it can be useful to see what the patient imagines spontaneously, and then amplifying the qualities and the experience when the patient imagines a secure interaction, to upregulate and emphasize the felt sense of security.  In general, sessions often have a cadence that is something like 2o minutes of talking to recognize the patient’s state and what they are coming into the session with, 20-25 minutes of imagery, and 1o minute debrief. The imagery process begins with a period of settling in and bringing attention to the bodily experience, in order to activate the early processing and memory system that was operative during IWM formation. Some clinicians choose to include calming the mind and body via concentration on the breath. This allows the client or patient to “drop in” to the embodied sense of being, and leave the world of analyzing and thinking, allowing for a more authentic and spontaneous experience. Research also shows us how fostering a calm and centered mind state best facilitates change. 

They begin by simply imagining themselves as a young child, quite innocent and carefree and curious. From here, the patient is invited to imagine that they grew up in a family different than their family of origin, with a set of parents completely and ideally suited to meet all of their unique attachment needs. And the IAT therapist encourages the patient to invite the IPFs into the imagined scene, having them at the ideal closeness and distance.  Subsequently, the therapist would draw attention to the felt sense of the IPFs by saying, “Notice what is it about these parents that supports you feeling more secure”

After allowing a little time for the patient to experience, the therapist invites the patient, if they feel comfortable to do so, to give some words to what they are imagining and experiencing.  The patient’s practice is to stay with eyes closed and just naturally report what they are imagining. If they respond by describing feeling even a little safer, then the therapist “marks the affect,” or amplifies saying something like, “Yes, really feel that feeling of safety, and really notice how they’re being with you that brings that feeling of safety.” After affirming any reported presence of a sense of safety with the IPFs, the patient is encouraged to feel that experience in the body. If the patient cannot imagine parents with whom they are feeling some sense of safety, then that is where the work stays. The therapist and patient collaboratively work together, both exploring what parental behaviors may feel safe to the patient.

There is a great deal of variability in how quickly patients adopt or adapt to an imagined world where their needs can be met. Some patients have gotten better remarkably quickly, while some others, over a long period of time, are still presenting with regular activations of attachment material. It seems to depend on the severity of the attachment disturbance, the current quality the patient’s support network, and the presence or absence of any co-occurring mental health or substance use disorders. The clinician embodies the attunement that can feel if the patient is actually absorbing these feelings in an authentic way or if they are trying to please the therapist. If, during the imagery, the patient spontaneously becomes upset or frustrated, then the IPFs can attune to that, and know exactly how to respond.

“They can help you see exactly what is wrong, why you are upset. That deep level of attunement allows them to clue in to what is upsetting you, and then they know just what to do and how to be to make whatever you’re upset about dissipate, even just a little bit. Imagine being so acknowledged and understood.” 

The patient is asked to imagine all the things the ideal parents could be saying and doing, and especially their ways of being, to make what they are upset about dissipate, even by a small amount. Depending on the level of rapport and how long you have been working with the patient, the therapist could suggest that the patient might want the parents to come closer, to receive some physical affection. While doing this, it is vital that the therapist remain attuned to the patient visually, to see if there is a reaction, either negative or positive, to the imagined contact. If there is a visible negative reaction, the therapist might say, “And if that contact doesn’t feel good, or safe, then notice that these parents can feel that, and they just move away. That’s just as easy for them.”

If the patient can begin to create or imagine a scene in which the parents are able to soothe them, the therapist would amplify that soothing by saying, “Notice, as they are taking care of you and soothing you, that there is nothing you have to do, there is nobody you have to be, no grades you need to have, it is just your very being, your very being as that child is more than enough for them. It gives them great joy, and they are not subtle about it. You can really feel it in your body. you can really tell that there is nowhere they would rather be than being together with you.”  And after introducing a prompt such as that, usually some space is given and then the patient is invited to give some words to what is happening in their imagination, to facilitate the co-creation of the imagery.

To slowly come out of the imagery, the therapist might ask the patient to imagine that they are getting a bit older, imagining that they always had these ideal parents, every step of the way, at every developmental milestone. “They were there, to hold you when you were scared, to support you when you were tired, to soothe you when you were upset, and to consistently remind you of your essential worth and importance. So that you can come to depend on the fact you’re your needs will be met every step of the way. And because these ideal parents were there to meet your needs and keep you safe, you come to deeply believe that the world is a safe place that can meet your needs. Really imagine that.”

To complete the imagery session, the patient is asked to let the scene go and slowly, gently bring their attention back to the body and breath in the present moment. As a way of closing the imagery, the therapist can let the patient know they will be counting backwards from 5 to 1, at which time the patient will be fully present and settled.

It is important to leave 5 to 10 minutes to debrief after the imagery, asking the patient to describe what happened, if they feel like giving some words to it, assessing their ability to track their own experience throughout the imagery.  Perhaps there will be a question, or something needing clarification. There may be a variety of responses to the sessions. Perhaps the patient could become elated and feel like they are in the middle of a breakthrough because they imagined these safe and secure qualities for the first time. Conversely, the patient can become sad, grieving the fact that their birth parents did not provide these conditions. When this occurs, it is totally normalized by the therapist, letting the patient know that sadness, or grief, is not uncommon in this process. But, that at the end of the sadness is healing.  And sadness is okay.  It is important to “touch” the sadness, to acknowledge it and see it, because it needs to be seen, like the puppy gnawing at your leg. If the patient’s experience of sadness and grief is apparent to the clinician during the imagery, then that sadness or grief can be included in the context of the ideal parent imagery, such that the IPFs notice and respond with loving, soothing care. In this way the patient has the experience of 'negative' emotions being welcomed into the body and then, most importantly, feeling safe enough to express and resolve them with the aid of the IPFs.

In order to provide more detail and clarity into how and why the AAI is used in a direct way to inform IPF work, I will present a clinical case. We will call him X.

Patient X

The following particular examples of my implementation of these methods are drawn from the principles that underlie Integrative Attachment Therapy. As with most psychotherapeutic tools, there are many ways to apply them, guided by the clinician’s knowledge and experience of them and most importantly, by the recognition of what any particular patient most needs at each clinical moment. For information about training in the IAT model and set of methods, or to sign up for the official training, see the Notes section at the end of this chapter.

Patient X, whom self-identified as a person with the preoccupied attachment strategy, began the AAI by providing exaggeratively positive words and phrases to describe the relationship with actual mother.  Among the early questions on the AAI, the participant is asked to give five words or phrases that would describe the relationship between themselves and their mother, as far back as they can remember, “but say age 5 to 12 is fine.” As the participant begins to list the words or phrases, the interviewer is writing them down because they subsequently refer to the list to ask for specific examples, or specific memories from childhood that would illustrate why they chose each word or phrase for the relationship. This same exact process is then repeated with the father.  These five words or phrases are the subject of further inquiry. Each word is brought to the subject’s attention, and they are asked to provide an actual memory, a concrete and authentic recollection of a time, moment, or scene from childhood that would illustrate why they chose the phrase. For example, when I asked Patient X why he chose “loving,” he paused in silence for about twenty seconds, and then said, “I don’t know,” with a big smile on his face.  He was encouraged to think a little longer, normalizing that it is a difficult question for many. He eventually provided a very general memory, stating that she was “always caring.” I again asked for a specific memory from as far back as he could remember of how the relationship was very loving and always caring. For “always caring,” Patient X described how his mother would pick him up from school with some regularity and he could trust that she would be there. When queried about how the ride home usually went, he stated that they would usually just talk about the mother. 

After going through the five words and phrases that Patient X presented for his relationship with his mother, we transitioned to his actual father. Again, he was asked to give five words or phrases that describe the relationship between himself and his father. He seemed to be much quicker to respond this time, and the words were quite different. “Tyrant.”  “Liar.”  “Needed me to be like him.” One can see rather quickly that there is a difference of perception between his early relationship to his mother and to that of his father. Patient X was then asked to provide evidence for his words or phrases, by providing a detailed memory, scene, or experience, from childhood that would illustrate why he chose those words. This time, he almost seemed eager to answer the questions. When I had asked him the same questions about his mother, he seemed to struggle to produce a memory. He was not as eager to answer. But for his father, for the word, “tyrant,” he provided a detailed and vivid memory of a time when he had made a pact with his dad, that if he pointed out when dad was getting enraged in the moment, that he would promise to stop and not take it out on Patient X. Then, some days after, his father got angry and Patient X told him, “Dad, you’re doing it.” And it made no difference. He did not abide by the agreement. In fact, it was one of the more scarier encounters Patient X recalls with his father.

The amount of information that I had gathered by the time the third AAI question and its inquiry was astounding. In that short time, I had formed a working hypothesis.   Patient X provided very positive and general words to describe his relationship with his mother. Yet, when asked to provide evidence for the words, he either did not have any evidence or the evidence he presented contradicted his initial word or phrase in some way. This notifies us that there is likely some degree of a dismissing strategy in place, namely idealizing. Idealization scores are raised when the subject gives positive words to describe the relationship and then does not have adequate evidence to support the positive picture that they paint. The clinician must see this as a defensive posture against having to authentically explore the difficulties of the relationship with mother. This is something that the IAT practitioner sees as important and useful. There is idealization of his mother, and “love” and “care” seems to be confused with his perceived duty to her and meeting her needs. We now know that his mother was over-involved and that he confused that for secure attachment. We know also that his father was an angry, rejecting, and untrustworthy man, with whom X is consciously and significantly angry.  The anger is less stated explicitly in the speech, but rather inferred through changes of tone, changes of tense, dropping into the parent’s voice or mocking them, etc.

I make my own clinical notes before sending it off to a reliable AAI coder through the AAI Institute at University of California, Berkeley. Shortly thereafter, I received X’s results in the form of a long report that was filled with clinical jargon. I knew to hand the report to Patient X is considered unethical. His final attachment classification based on this coder was U/E2/E1/F2. Unresolved trauma in the form of physical abuse from dad and some involving or preoccupying anger towards his mom and dad, with some marked passive speech. He did not qualify for full criteria for a Dismissing score, but F2 (Somewhat Dismissing) is evidence of some of the idealization of mom mentioned earlier.

Upon getting the results, I composed a short summarization in non-scientific terms, set some reasonable goals with ideas on how to get there with IAT, and in our next session, talked about how the AAI findings are going to directly influence how we use X’s IPFs. I did not simply forward the raw data report to the patient and say, “Have a read and we will chat about it soon.” I created my own synthesis of the information that I knew would be palatable and make sense to Patient X. After answering any of X’s questions, we were ready to begin his first co-created imagery session.

Upon receiving the results for Patient X, I took a short time to synthesize the important ideas and concepts and how the coder arrived at them, and then together, we went through the results and talked about ways that we could create situations and ideal figures that would nullify some of the ways that his needs were not met as a child. We know that X’s mother was over-involved and role-reversing at times. Regarding positive opposites, his ideal mother will emphasize the expressed delight in his being and to encourage his best self. A way to address this is for the therapist to suggest, “Notice how your ideal mother has no agenda for you. Feel the spaciousness in that. She wants you to be your strongest, most unique self. She would never put herself before you, for any reason at all. And begin to notice how she can give you a feeling of spaciousness and trust. You don’t even have to ask, because as soon as you start to feel crowded, she can attune to that and sense it and adjust and move away.  Imagine that.”

We know that Patient X sees his father as a predator. We know that he is scared of his father and also found out through the AAI that he does indeed have unresolved physical abuse from dad. This is something to be taken very seriously, mindfully, and gently, as we are now beginning to touch some of the trauma. As difficulty arises in his imagination of a safe father, the therapist might say, “Imagine everything about this figure is completely nonthreatening. And in fact, notice that he sees that this is difficult for you.He totally understands. He really sees you.  Experience what that’s like in your body, to be seen this way, and have it safe and maybe even a little soothing.  Notice also that you don’t have to figure it out right away. Your ideal dad knows this is difficult, and if it takes you time to get comfortable with him, that is completely fine with him.” 

Thus, we have taken mom’s overinvolved/role reversing behavior that we learned about on the AAI and imagined an ideal mother figure that is completely supportive of his best and most unique and independent self, every step of the way. We learned that X’s father was angry and volatile on the AAI, so we imagined an Ideal Father figure who was completely non-threatening, spacious, warm, attuned and kind. Through consistency and repetition, what I witness in Patient X after working with him for almost two years, is a man who can now easily and naturally evoke and imagine his ideal parental figures. Even when he does not directly imagine them, he experiences that they are available to him, because they have now integrated and become part of his secure self. When he finds that his partner fails to meet his needs entirely, rather than exploding in anger, he turns inward and pauses and gets the reassurance and clarity he needs from his IPFs. This stops the activating material before it becomes a true belief, and allows X to stay present with his partner and able to discern the difference between an actual rupture and an internal projection from his childhood. He has a newly developed sense of self and is pursuing his dream of becoming a full-time travelling musician. When we retested Patient X with an AAI 12 months after we started treatment, he scored as F1a. In other words, he was no longer testing as Unresolved due to the physical abuse of the father and he was no longer testing as anxiously/angrily preoccupied with mom. Rather, it was clear that he had made a conscious effort to redirect his attention away from his preoccupied parents and more towards his own self-development, discovering who he is in the absence of needing to please his mom (F1a).

In conclusion, the Adult Attachment Interview (AAI) is a valuable assessment for clinicians working in the attachment field. One gets an abundance of information about the mind-state of the patient with regard to attachment, and the coder can easily track the coherence in their speech. It clearly goes down when talking about unresolved material and then returns to baseline when the next topic is broached. One gets a list of “positive opposites,” of ways that the Ideal Parents can correct the misgivings of the biological parents. And the IAT therapist can reliably refer to the 5 qualities that promote secure attachment if ever feeling “stuck” or losing concentration.

Does the patient have the ability to self-reflect in a coherent way? What happens to the patient when difficult material arises? This can tell the IAT therapist a great deal about how to attune and be with the patient in a safe and non-threatening way. And most importantly, as it relates to this chapter, there is a way of collaboratively discussing the AAI findings with the patient without sending them a quantified analysis of their entire life and behavior. If the clinician wants to create a report, then consider taking the most important pieces, putting it into terms that the patient can understand, and talking about how you as the clinician are going to work together with the patient to address these issues. And to be clear with the patient, that the findings on the AAI are not sacred or divine; that even “reliable” coders score interviews differently sometimes. In this way, there is less pressure and performance anxiety and more collaboration, setting up a nice and easy rapport at the beginning of treatment rather than a power dynamic. 

Notes

1. While one does not need to be certified to administer the Adult Attachment Interview (AAI), it is vital that coders become empirically “reliable” through completing the training at the Center for Attachment Research at https://center-for-attachment.com/training-opportunities-2/.  Following your training, you will have to score three rounds of 10 AAIs and achieve at least 80% reliability (scoring the interview the same as the creators) of arriving at the same scores as the creators of the test.  The process takes multiple years.
2. Integrative Attachment Therapy (IAT) is the psychotherapeutic model that envelopes the Three Pillars of attachment repair process — enhancing collaborative abilities, expanding metacognitive skills, and creating positive internal attachment representations through the Ideal Parent Figure imagery (IPF) process.  Clinicians who wish to explore training can do so and certification in this approach can find information at www.integrativeattachmenttherapy.com.  
3. For a number of unfortunate reasons, there is quite a bit of confusion in the general public about what exactly IPF is and who is qualified to practice it.  What began as a component of an integrated psychotherapy model has been taken out of context by some people without appropriate clinical training and applied on its own as a “guided meditation.”  The spread of this mis-application through social media has been unfortunate -- it has emboldened non-clinicians to apply a clinical method, which creates risk for harm to people with histories of relational trauma. 

Acknowledgments

This chapter would not be possible without the selfless and caring support from the co-creator of the treatment, David S. Elliott, Ph.D.  I also want to acknowledge Howard Steele, Ph.D. and Miriam Steele, Ph.D. for their unwavering confidence and belief in my abilities.  

References

Ainsworth, M. D. S. (1973). The development of infant-mother attachment. In: B. M.

Caldwell & H. N. Ricciuti (Eds.), Review of Child Development Research (Vol. 3) (pp. 1–94).  Chicago, IL: University of Chicago Press.

Bowlby, J. (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development.

New York: Basic Books.

Brown, D. P., & Elliott, D. S. (2016). Attachment Disturbances in Adults: Treatment for

Comprehensive Repair. New York: W. W. Norton.

Elliott, D.S. (2021) Co-creating secure attachment imagery to enhance relational healing.

Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, Vol. 15, June 2021: pp. 36–55.