Attachment Theory in Clinical Work with Adolescents

Karine Dubois-Comtois^1,2*, Chantal Cyr³, Katherine Pascuzzo⁴ and Mylène Lessard¹

¹Department of psychology, Université du Québec à Trois-Rivières, Trois-Rivières, Canada

²Hôpital du Sacré-Coeur de Montréal, Montréal, Canada

³Department of psychology, Université du Québec à Montréal, Montréal, Canada

⁴Department of social psychology, McGill University, Montréal, Canada

*Corresponding Author:

Karine Dubois-Comtois
Department of psychology
Université du Québec à Trois-Rivières, Québec, Canada
E-mail: karine.dubois-comtois@uqtr.ca

Received Date: August 28, 2013 Accepted Date: October 15, 2013 Published Date: October 25, 2013

Citation: Dubois-Comtois K, Cyr C, Pascuzzo K, Lessard M (2013) Attachment Theory in Clinical Work with Adolescents. J Child Adolesc Behav 1:111. doi:10.4172/2375-4494.1000111

Copyright: © 2013 Dubois-Comtois K, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Adolescence is a critical period of transformation that can result in the emergence or consolidation of psychopathology. Attachment theory offers a framework for understanding adolescent normative and pathological functioning as well as relevant intervention models that promote the emergence of individual and interpersonal abilities. This article provides a framework for clinicians interested in the therapeutic application of attachment theory with adolescents. It addresses the salient aspects of attachment during the adolescence period and its impact on adolescents’ adaptation and difficulties. The article also provides a brief description of the Adult Attachment Interview (AAI), a method of choice to assess adolescent attachment state of mind. Finally, the clinical application of attachment theory with adolescents is described and supported with clinical vignettes.

Keywords

Attachment; Adolescence; Assessment; Intervention

Introduction

Attachment theory in clinical work with adolescents

According to attachment theory, the quality of present attachment relationships with the parents, as well as skills acquired in a secure attachment relationship since childhood, are key features in solving developmental issues linked to adolescence. This theory focuses on individual and relational developmental processes. Not only does it propose a framework for understanding adolescent normative and pathological functioning, but it also offers practitioners a pertinent intervention model for the emergence of skills that were underdeveloped within dysfunctional parent-child relationship.

To date, several theoretical and empirical studies were conducted on child attachment. Considering that attachment is one of the most important developmental aspects in predicting child socio-emotional adaptation it is not surprising to see the numerous clinical studies demonstrating the benefits of clinical programs based on this theory [1,2]. However, these studies have mostly dealt with the infancy period. Thus, little information exists on the role of attachment, its assessment, and clinical application for adolescent populations. Yet, attachment theory provides an interesting framework for understanding the development of autonomy, a crucial developmental change of the adolescent period. Accordingly, some researchers in the field of attachment [3,4] have attempted to document our knowledge of adolescent attachment. Based on these studies, which belong to a relatively new field of research, the present article sheds light on the prominent aspects of adolescent attachment, including its conceptualization as well as its assessment. In doing so, we lay the foundation for the application of attachment-based therapeutic practices aiming the well-being of troubled adolescents.

Attachment in adolescence

Attachment security refers to the individual’s capacity to seek comfort from a meaningful figure when in distress and, once soothed, to become available to explore the environment and acquire new learning experiences [1]. Throughout development, attachment relationships provide the individual with emotional support and a feeling of continuity and comfort, especially during stressful periods and moments of important change, such as the transition into adolescence or adulthood [5]. Attachment theory also suggests that daily interactions between young children and their parents are internalized into internal working models – including representation of self, others, and relationships – which influence the child’s anticipation of parental behaviors as well as the child’s behavior towards the latter and eventually towards others [6].

Redefining parent-child relationship in accordance with the developmental process of individuation

In adolescence, the parent’s double role of ensuring comfort and protection and promoting exploration is still present, but must be carried out according to the child’s current needs. Adolescent attachment is the result of both the adolescent and parent’s capacity to redefine their attachment relationship by taking into consideration the individuation process, that is, developmental changes at the social, cognitive, and emotional levels [7]. According to attachment theory, this redefinition is mainly achieved through parent-adolescent exchanges that include the communication of emotional states and related thoughts of each member of the dyad [8]. Co-construction of such relationships represents a key element in maintaining or developing a secure attachment at this age.

A striking aspect of the individuation process is the adolescent’s increasing need for distance from the parent. Time spent with the parent becomes less important, as physical proximity is no longer necessary to ensure protection and comfort [9].

Adolescents’ trust in their parents availability and accessibility in times of need are key features of a secure attachment during this period [10,11]. Parents remain accessible through verbal exchanges but gradually encourage the adolescent’s inner movement of exploration at a greater physical distance. This not only allows adolescents to internalize a secure representation of their attachment figure, which they can refer to in their absence, it also promotes exploration outside their relationship. Indeed, in addition to the development of new social relationships with peers and/or romantic partners exploration extends the physical environment to include exploration of personal ideas and emotional states [12,13]. Given the access to symbolic rather than physical parental presence, attachment during adolescence becomes an individual rather than a relational characteristic. In other words, attachment becomes a state of mind which guides adolescents’ behavior and thought, as well as stress regulation strategies [14,15].

Cognitive, emotional, and social development

In addition to being influenced by the quality of parent-child communication, adolescent attachment is influenced by cognitive, social, and emotional developmental changes occurring during this period. Figure 1 illustrates the interrelations between parent-child exchanges, adolescent development and attachment representations, and how this dynamic model is especially salient in the early adolescent period. The bottom of the figure presents intervention procedures that will be discussed in the last section of the article (Figure 1).

Notably, at the cognitive level, the development of abstract reasoning and better differentiation of self and others helps adolescents realize that certain individuals are capable of meeting their attachment needs than others [15]. This cognitive process facilitates adolescents’ capacity to re-evaluate their representations of attachment figures, at the general level. However, those with an insecure attachment relationship are more likely to endorse false perceptions or cognitive distortions of affective situations, as well as metacognitive problems, that may influence the course of their cognitive development and mentalization capacities during therapeutic tasks [16,17].

Intense and changing emotional states in adolescents can easily activate their attachment system, leading them to feel emotionally submerged and powerless in overcoming difficulties [7]. Adolescents’ emotional lability, combined with individuation needs, challenges the capacity to seek out parents in stressful situations and highlights the importance for parents (and therapist) to preserve optimal communication [18]. This is particularly the case in adolescents who have developed an insecure attachment and who are more vulnerable to temperamental and behavioral disorders [3,19-22].

Intimate social relationships with peers and romantic partners are experienced as new attachment relationships to which adolescents can turn to in stressful situations or moments of adversity [15]. These new attachment figures can answer needs that former figures were unable to fulfill. Markiewicz et al. [12] have shown that adolescents rely more on their mothers to satisfy exploration needs, while they are more likely to turn to friends in stressful situations, and use romantic partners for seeking comfort. The expansion of one’s network of attachment figures promotes the revision of attachment states of mind by reinterpreting affective childhood events in light of new relationships with others. This openness in establishing new attachment relationships lays the foundation for the development of an attachment relationship with the therapist, which will serve as a base for subsequent therapeutic work.

Adolescent attachment assessment

The Adult Attachment Interview is the gold standard measure for assessing adolescents’ attachment state of mind [14]. Certain authors have modified the interview in order to administer it to children as young as 10 years old [23]. This semi-structured interview centers on the description and assessment of relationship experiences with parents in childhood, as well as with the memories of attachment related stressful events. First, the interview assesses discourse coherence, that is, the capacity to express oneself clearly and to organized one’s thoughts when recalling emotionally charged events, in contrast to the incoherence of impersonal discourse or contradictory and dissociated content discourse. By helping the individual reveal less conscious aspects of attachment relationships, this instrument also gives access to defensive processes used by adolescents to organize attachmentrelated information. Bowlby described four different models of cognitive processing for dealing with attachment-related information: a first model of cognitive processing based on flexible integration and three others based on defensive exclusion (deactivation, cognitive disconnection, and segregated systems) [24]. Knowledge of these defensive processes provides the therapist with a better understanding of adolescents thought organization (and that of their parents) and relational functioning.Each of the four attachment categories assessed with the Adult Attachment Interview refers to one of the models proposed by Bowlby [24].

Flexible integration

Flexible integration is present in individuals with a secure or autonomous attachment [6]. Adolescents, who display flexible integration, express attachment related experiences and affect coherently, give importance to attachment relationships, and describe their parents as trustworthy. Specifically, these adolescents are capable of integrating both positive and negative emotions associated with past experiences and show a reflective functioning style highlighting their capacity to metacognitively reassess attachment events and representations [22].

Defensive exclusion: deactivation

Conversely, attachment insecurity is associated with defensive exclusion of affective and attachment-related information [6]. More precisely, deactivation is characteristic of an insecure dismissing attachment. In order not to activate their attachment system, adolescents who display deactivation do not focus their attention on affective states and personal needs. In doing so, they avoid dealing with emotions stirred up by attachment experiences [25]. In their discourse, these adolescents tend to minimize or even denigrate the importance of attachment relationships. They remember few or no relational experiences with their parents and normalize the life they had with them. While negative situations and their consequences are generally denied, attachment figures are idealized, despite the fact that they ignored or minimized the adolescent’s distress signals during childhood [25].

Even though adolescents with dismissing attachment are seen as quite functional they are perceived by their peers as being the most hostile, and this is probably linked to their denigration of relational and emotional needs [26,27]. Furthermore, dismissing attachment during adolescence has been associated with greater substance abuse, delinquency, and behavior disorders [22,28]. Their inability to acknowledge or deal with negatively charged emotions seems to render these adolescents vulnerable to acting out behaviors.

Defensive exclusion: cognitive disconnection

Cognitive disconnection is a defensive process mostly used by individuals with insecure preoccupied attachment [6]. Adolescents who display cognitive disconnection redirect attention away from events or Individuals responsible for their emotional reactions. For example, feelings of anger are explained by a parental divorce rather than the fact that parents were unavailable Thus, these adolescents no longer recognize the reasons at the source of their emotional state. Moreover, their discourse is filled with uncertainty, anger, and selfblame. Generally, preoccupied adolescents continue to experience great frustration concerning former and present attachment experiences. Ongoing preoccupations with past events cause these individual to remain emotionally involved, though they are incapable of describing these emotions coherently [19].

Adolescents with preoccupied attachment are also more likely to have parents who inconsistently respond their attachment needs, causing them to develop strategies that maintain their attachment system activated [25]. Indeed, preoccupied adolescents tend to exaggerate the expression of emotion in order to increase their chances of receiving attention from those likely to answer their needs. This pattern of behavior is supported by studies showing that preoccupied adolescents exhibit higher levels of depressive and anxious symptoms stress, and feelings of loneliness [4,19,22,29].

Defensive exclusion: segregated systems

Segregated systems are characteristics of adolescents with an unresolved insecure attachment state of mind. According to Bowlby when an attachment experience is traumatic (e.g., loss of an attachment figure, sexual or physical abuse) and too difficult to handle, the experience as well as its emotional components are completely segregated from conscious awareness. Consequently, when the traumatic event is recalled, the adolescent possesses no strategy to efficiently integrate or contain the re-enacted segregated material [24]. During the AAI interview, adolescents’ discourse can be overwhelmed by fear and helplessness. Such emotional states are likely to disorganize the adolescent and lead to verbal acting outs, as seen in remarks filled with hostility or, at the opposite end, great passivity. Discourse regarding traumatic events is often incoherent and sometimes even dissociated from reality [28]. The lack of stress regulation strategies is mainly due to the fact that the traumatic event involves the attachment figure. Accordingly, the attachment figure can no longer be counted on as a source of comfort, or help to give meaning to the traumatic event. Instead, he or she is the very source of fear activating the attachment system and related distress [30]. Due to the great difficulty for self-regulation, unresolved adolescents are especially vulnerable to psychopathology. Noteworthy are studies showing adolescents with unresolved attachment representations at great risk of showing suicidal ideation as well as dissociation symptoms [31,32]. Moreover, Wallis and Steele observed that 59% of adolescents from a clinical sample showed unresolved attachment [33]. Finally, literature review showed evidence that this attachment group had the greatest risk for developing internalizing symptoms compared to the other attachment groups [34].

Adolescent attachment intervention

Although few attachment studies have been conducted with adolescents, this theory offers relevant paths for guiding intervention strategies with this population. The most important assumptions to be considered in the clinical application of attachment-based interventions are summarized in the following section. Two vignettes then serve to illustrate the clinical relevance of attachment theory with this age group.

The first assumption for clinical application of attachment theory is that the target of the intervention is the individual’s relational functioning mode. Accordingly, the primary objective of the intervention is to promote the development of skills that normally emerge within an optimal relationship with the attachment figure. Here, the individual’s developmental age needs to be considered. The second assumption is that the intervention must offer individuals the possibility to give new meaning to their attachment experiences. The third principle is that goal attainment can only be achieved with a therapist who assumes the role of a secure attachment figure.

Several therapeutic procedures may be used in the clinical application of attachment theory. In this article, we first address individual therapy, which refers to a more traditional form of therapy. We then present a form of therapy less known to clinicians and which, in our opinion, is worth using more frequently to promote adolescents well-being: parent-adolescent therapy. For many, it might seem paradoxical to favor such a therapeutic procedure in adolescence. Nevertheless, Obsuth et al. [35] demonstrated that improvement in the quality of parent-adolescent exchanges and increases in parental knowledge of attachment principles proved effective in reducing oppositional problems in adolescents. In this perspective, parentadolescent therapy seems an excellent alternative to individual therapy when adolescents exhibit difficulties at the mentalization level.

Individual therapy

In 1988, Bowlby proposed that the main objective of attachmentbased therapy is to support the patient in re-evaluating and restructuring insecure attachment representations by using the therapeutic alliance as a new model of relationship functioning [8]. Bowlby’s model thus highlights the previously-mentioned principles in the application of attachment theory in therapy. In fact, individuallybased therapy aims at accompanying adolescents in the revision of their attachment models. The best way to attain this goal is for the therapist to act as a secure attachment figure for the distressed adolescent [36]. Accordingly, through interactions with a responsive and available therapist, adolescents can begin to view the therapist as someone who is sensitive to their experiences of distress. The therapist can then accompany the adolescent in the reinterpretation of past difficult experiences by containing their distress and providing it new meaning. The therapist, who is viewed as a secure base, can then more easily encourage adolescents’ exploration of thoughts and feelings, including anxieties as well as needs [36]. Through this therapeutic process, more adequate relational behaviors are encouraged. Thus, as the therapeutic alliance is established, an “attachment relationship” is fostered between the adolescent and the therapist, which will then act as the key factor for promoting change within the adolescent.

Observing adolescents’ behaviors and analyzing their discourse with regards to defensive processes also helps the therapist in tailoring a specialized intervention plan based on the adolescent’s individual needs. It is therefore crucial that the therapist be attentive to how the adolescent relates to him or her in order to gain access to the adolescent’s schematic representation of the patient-therapist relationship [37]. First, the therapist must be vigilant with regards to how the adolescent interacts with him or her in distressing situations. Does the adolescent easily confide in the therapist? Can the adolescent verbalize negative feelings or distress? Are needs and feelings minimized or exaggerated? Does the adolescent seem afraid or helpless when faced with stressful situations? Second, it will be important to consider the adolescent’s perceptions of the therapist, as this can provide important information with regards to the adolescent’s relational representations. For example, is the therapist described as being sufficiently available? Conversely, is he or she idealized, denigrated, perceived as intrusive or even described as distant, inaccessible or unpredictable and frightening? Keeping in mind defensive processes associated with attachment theory, the therapist must also be attentive to the adolescent’s reactions with regards to moments of separation, such as holidays or missed sessions. According to attachment theory, moments of separation can trigger the activation of the attachment system and thus provide the therapist direct access to the adolescent’s preferred attachment strategy and relational functioning style [5].

Through adolescents’ discourse, the therapist also gains access to their representation of attachment experiences with parents. As is the case when assessing individual’s attachment strategies during the Adult Attachment Interview the therapist must be attentive to adolescents’ description of how their parents responded to their distress, as well as their recollection of situations that activated their attachment system (i.e., separation from parental figures, loss of loved ones, traumatic events) [14]. The capacity to recall stressful relational events and the coherency of their discourse are key elements revealing attachment representations and defensive processes.

Access to adolescents’ mode of relational functioning allows the therapist to then choose an intervention strategy best-suited at fostering a secure attachment. Notably, when adolescents possess an autonomous or secure attachment state of mind, they value relationships, be it with the therapist or others in their environment. It is therefore easier for adolescents’ to become fully committed to the therapeutic process. Their capacity to internalize and reflect upon both positive and negative internal emotional states facilitates therapeutic intervention, making them ideal candidates for therapy [38]. However, most adolescents seen in therapy possess an insecure attachment and may present dysfunctional relational styles thus complicating the therapeutic process.

A major challenge for therapists when working with adolescents who have developed an insecure dismissing attachment is to establish a relationship of trust. Furthermore, the capacity to reflection upon one’s feelings and thoughts is often compromised in adolescents with a dismissing attachment style especially with regards to emotionallycharged relational situations [39]. Thus, when these emotions are activated during exchanges with the therapist, they affect the adolescent’s capacity to think logically. The therapist’s role is therefore to provide the adolescent with strategies to help him or her face these negatively charged emotions so as to allow a clearer understanding of internal states. The therapist must therefore acknowledge and recognize the adolescent’s suffering, and then responds to it by naming the emotion being experienced. By helping the adolescent identify and experience emotions, the latter may slowly begin to abandon the use of avoidant and deactivation strategies. One must realize however that when adolescents with a dismissing attachment face their emotions, which have been repeatedly suppressed, they can quickly become overwhelmed. This is especially true when the adolescent is faced with feelings of parental rejection experienced during childhood. Because avoidance is a defensive mechanism linked to dismissing attachment, the therapist must pay close attention to the adolescent’s absences, which may be signs that he or she wishes to prematurely end therapy. Nevertheless, some researchers have observed that in clinical populations, it is adolescents and adults with dismissing attachment profiles who profit the most from therapy, since they have the opportunity to discover an internal world to which they had no previous access [40,41].

As for the adolescent with an insecure preoccupied attachment, the therapist must focus on the individual’s cognitive and emotional distortions in order to establish a more coherent discourse between the adolescent’s relational experiences and affective states. This therapeutic strategy is directly linked to the defensive process of cognitive disconnection used by adolescents, where negative emotions are linked to unsolicited situations so as to avoid dealing with conflictual feelings associated with the relational situations that in fact provoked them. This task is related to the development of reflective functioning described by Fonagy and Target [42] that is, the capacity to understand one’s own behaviors and those of others by drawing on one’s feelings and thoughts. Reflecting on relationship issues by integrating different perspectives helps the adolescents to make sense of experiences and reinterpret past events based on a greater understanding and better integration of reality. Moreover, since an important aspect of preoccupied attachment is dependency on attachment figures, the therapist must allow adolescents to explore their experiences on their own. Otherwise, the therapist may risk reproducing a dependant relationship whereby he or she is solely responsible for the successful outcome of the therapy, instead of the adolescent.

Lastly, in order to assess the presence of an unresolved state of mind, the therapist must pay particular attention to the manner with which the adolescent recalls potentially traumatic events. In fact, he or she must pay special attention to flaws in the organization of the adolescent’s discourse, for example, temporal and spatial incoherencies, signs of dissociation, prolonged pauses, and sources of profound anxiety, including moments when adolescents blame themselves for the trauma [14]. The presence of fear and helplessness in the adolescent’s discourse is also considered to be a marker of an unresolved attachment. The therapeutic process will make it possible to work on the traumatic aspects that disorganize the adolescent’s thoughts and behaviors and place him or her at greater risk of showing dangerous “acting out” behaviors, be it towards themselves or others. Given that traumatic events are dissociated from events consciously accessible to the adolescent, some may give the impression of a false sense of well-being. The first intervention strategy to be used with these adolescents is therefore to help them recognize their dissociated or “acting-outs” behaviors (e.g., aggressiveness) so that they can become aware of their feelings of fear and helplessness [43]. This first step is essential and will later help the adolescent reinterpret past attachment experiences, as traumatic as they may be, and give them new meaning.

The relevance of attachment theory in the clinical setting is illustrated in the following case study. A seventeen-year old adolescent female is seeking help for problems relating to self-acceptance. In the therapist’s presence, the adolescent is very distant and reports very little on the thoughts and feelings she is experiencing. When questioned on her relationship with her parents, the adolescent reveals a normal past with little detail. Several weeks are spent fostering a relationship of trust between the adolescent and her therapist. Once trust has been established, the therapist is then granted access to the adolescent’s profound feelings of rejection experienced with respect to her parents, especially her mother. The therapist’s absences, even when discussed in therapy, caused the patient to experience feelings of rejection. The adolescent coped with this rejection by missing appointment sessions, as a means to distance herself from the therapist. Through their sessions, the adolescent realized that she aimed to maintain distance in all her relationships and that her low self-esteem and negative self-image were linked to feelings of rejection in the presence of others. This example illustrates how relational styles and associated attachment model, an insecure dismissing attachment in this particular case, can greatly impact adolescent functioning. This relational style of avoidance and affect minimization was identified by the therapist, discussed with the adolescent and worked on during therapy, which then promoted the adolescent’s development of trust and openness. This change, which occurred first within the therapeutic alliance, was then extended to the adolescent’s other relationships. Indeed, the adolescent was later able to confront her parents with her needs which, until then, had been repressed.

Certain studies have shown how therapeutic interventions, whether short or long term, promote increased attachment security in adolescents x and in distressed adults [41,42,44,45]. Creating a secure attachment relationship with a significant person was described by suicidal adolescents as being a turning point in their progress, which put an end to their suicidal thoughts and promoted a more positive self-image [46-48]. According to Bostik and Everall [46] when adolescents believe they have an important figure in their environment that is consistently available to respond to their needs, they tend to feel less isolated and in turn can identify and draw on their strengths to develop healthier interactions with others. Thus, establishing a secure therapist-adolescent bond, which allows the adolescent to revise their representation of attachment relationships, seems to be a promising and desirable intervention strategy for distressed adolescents.

Parent-adolescent therapy

The goal of parent-adolescent therapy is to encourage adolescents and their parents to live a new relational experience, allowing them to reinterpret their representation of the relationship. This therapeutic procedure offers the dyad new ways of communicating which in turn encourages the development of healthier and more secure interactions and reduces inadequate behaviors serving to maintain insecurities within the relationship. The principles of parent-adolescent therapy could also be applied to family therapy, since the family system consists of several subsystems including the parent-adolescent dyad.

Dyadic therapies centered on attachment theory were initially developed and applied with parents and their young children, with the majority of interventions relying on video feedback [2,49]. Although dyadic therapies with adolescent samples have received very little attention to date, this modality is highly applicable to this particular population, since parent-adolescent relationships are often at the core of the youth’s vulnerabilities. According to Atger parents often feel distressed and powerless in coping with their adolescent’s difficulties, which activates their own attachment system, potentially contributing to the development of an insecure attachment relationship with their adolescent [50]. Within the framework of parent-adolescent therapy, it is therefore important for the therapist to be equally sensitive to parents’ distress in order to assist them in becoming a more adequate base of security for their adolescents. Building a relationship of trust with the parent as well as the adolescent is therefore a pre-requisite to successful parent-adolescent therapy. Kobak and Esposito [51] proposed that trust in the therapist’s availability and sensitivity is only created once the latter shows empathy and openly communicates his or her intentions and ideas to the dyad. The therapist’s approach can then serve as a model for the dyad in promoting more adequate communication skills and genuine interest in one another.

However, insecurity within the parent-adolescent dyad leads to rigid thinking, where each member of the dyad considers only the information that confirms his or her internal model [24]. Thus, parent-adolescent exchanges occur in such a way as to confirm their expectations, that is, those of a partner who is unavailable/rejecting, intrusive/dependent or helpless/hostile. If the parent-adolescent exchanges are absent, unpredictable, or characterized by negativity, the therapist’s role is to re-establish more adequate communication and empathy within the dyad. To accomplish this goal, the therapist invites the dyad to interact with one another, either through discussions, role playing, or fun activities, so as to experience new ways of interacting [49]. The therapist then focuses on each person’ point of view and reformulates the difficulties experienced by the dyad in light of these different viewpoints. This method can encourage each member of the dyad to be more open to the other’s ideas and promote a new way of experiencing difficulties within their relationship. This reinterpretation based on new information, allows each partner to revise their representations of themselves and of the other, not only by considering the other’s viewpoint but the shared viewpoint of the dyad. In this way, the therapist helps the dyad to replay past experienced events and recreate the meaning attributed to them. This therapeutic approach allows each member of the dyad to adjust to the other’s needs and develop more mutual and respectful exchanges.

The therapist then encourages each member of the dyad to observe the negative and positive effects they have on each other. This approach allows the therapist to highlight the different emotion regulation strategies of each member of the dyad and the impact of these strategies on the quality of their communication. More specifically, the therapist can reinforce the strengths and adaptive strategies of each member. Adaptive conflict resolution in the parent-adolescent relationship encourages a more secure family base, allowing parents to become a source of support for the adolescent in the development of their skills and quest for autonomy. Thus, not only does the therapist help the parent and adolescent to show interest in each other’s experiences but he or she also proposes that they experience, during the course of therapy, a new way of interacting with one another in the here and now. These new interactional behaviors can then be repeated outside the therapeutic sessions and may be generalized to other interactional contexts. From an experiential standpoint, this type of therapy is particularly suitable for adolescents who present mentalization problems, rendering individual therapy more challenging.

This second clinical vignette highlights the value of parentadolescent therapy. A mother consults with her 14-year old son, for the latter is experiencing feelings of fear which have been impeding his daily functioning. Despite his distress, the adolescent does not wish to seek help and, at the first session, threatens his mother for insisting on pursuing therapy. In the following sessions, the therapist notices that the adolescent seems to control his mother’s activities and that this seems to quell his fear of losing her. At the same time, the mother feels powerless with regards to her son’s suffering, and is also experiencing her own personal difficulties. The therapist thus hypothesizes that this mother-adolescent relationship is based on a role reversal interactional style characterized by the adolescent’s hostility and the mother’s helplessness. Their lack of trust in one another and their fear is also omnipresent in their exchanges. The therapist begins by being attentive to the individual fears and desires of the mother and her son. Over the course of sessions, the therapist’s listening skills and sensitive questioning were slowly adopted by the mother and the adolescent using the principles of modeling. Through this new interactional experience, the mother began to assume her parental role which in turn promoted the adolescent’s feelings of trust towards her. By using the therapist as a secure base, the mother succeeded in rediscovering her parental role, which had a comforting effect on her son, thus diminishing his fears. Trust in themselves and in each other allowed both mother and son to better communicate their respective needs to one another.

Limits to attachment-based approach

Although parent-child attachment is an important paradigm in the prediction of child psychosocial adaptation, certain limits need to be addressed. One important issue to consider is that the parent-child attachment relationship is only one of many predictors of child development and well-being. Accordingly, when studies over emphasize the role of attachment-related concepts, they tend to undermine the influence of other important aspects of the family environment, including mother and child characteristics. For example, Dubois-Comtois et al. showed that maternal psychosocial distress and child gender were significant predictors of child disorders in middle childhood, even when accounting for the quality of the parent-child attachment relationship [52]. In addition, meta-analyses conducted in early childhood have found significant small to medium effect size linking insecure attachment and internalizing behavior problems [53-55]. Together, these results suggest that variables other than child attachment might play an important role in explaining child and adolescent psychopathology. In light of these findings, attachment theory should serve as a model to enhance security of attachment, including the therapist-adolescent relationship. Clinicians should thus refrain from basing their entire intervention program solely on attachment-related principles. Specific attachment-based intervention should only be conducted when the clinician suspects that it is related to the adolescent’s main issue with regards to maladaptation. In most cases, attachment-based intervention should be used in conjunction with other intervention strategies. For example, cognitivebehavioral therapies (CBT) have been found to be effective in reducing adolescent depression and anxiety disorders [56-57]. Meta-analyses have also reported the effectiveness of CBT in treating anger-related problems and antisocial behaviors [57,59]. Other therapies such as interpersonal psychotherapy, dialectical behavior therapy, and longterm psychodynamic psychotherapy have also proved to be effective in treating adolescent disorders [60,61,62].

Conclusion

The aim of this article was to inform clinicians of the importance of attachment principles in therapeutic work with adolescents. Indeed, the adolescent’s attachment background has been shown to have a considerable influence on his or her ability to cope with the developmental issues of this crucial transitional period. This article also shows how cognitive and socio-emotional changes lead to disturbances and unavoidable revisions of the adolescent’s internal working models of attachment. In order to provide the clinician with attachment-based intervention tools, this article focused on the importance of assessing the adolescent’s defensive processes both at the behavioral and verbal levels. It is important for the clinician to consider the adolescent’s relational style during intervention. Regardless of the therapist’s theoretical approach and preferred therapeutic strategy, that is, individual versus parent-adolescent therapy, the notions stemming from attachmentbased studies suggest interesting intervention avenues for promoting attachment security in adolescents and overcoming certain deadlocks.

It has been clearly demonstrated that adolescents with the highest risk of developing adaptation problems present an insecure attachment profile. Future studies in this field can help to identify individual differences associated with insecure classifications (dismissing, preoccupied, unresolved) in adolescence. Furthermore, though several authors have addressed the relevance of attachment theory in clinical interventions with adolescents, few studies have empirically verified this question. Accordingly, future clinical studies should assess 1) which intervention modalities are the most effective in treating adolescent samples; 2) pathologies or difficulties for which clinical principles of attachment theory are indicated, and finally 3) optimum duration of such interventions.

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