PRACTICE REVIEW The Use and Limitations of Attachment Theory in Child Psychotherapy Karen Zilberstein Smith College School for Social Work Attachment theory and research has proliferated in recent years, spawning new ideas and applications to child therapy. Some of those interventions are creative and useful and rest on solid theory and research, whereas others derive from tenuous assumptions. As an important developmental construct, attachment plays a role in every therapy, but defining that role can be difficult. Therapists must recognize the significance of attachment in treatment but not at the expense of recognizing and treating other issues. This article provides an overview of attachment theory and attachment-based interventions and discusses how to apply those constructs to therapeutic work with children. It reviews attachment theory, assess- ment, and treatments, and discusses how attachment-focused interventions can be combined with other therapeutic needs and methods. It also considers limitations in the current clinical application of attachment and makes recommendations for further research. Keywords: attachment, child therapy, developmental psychopathology, self-regulation, comorbidity Attachment theory and research has proliferated recently, spawning new studies and applications to therapy. Originating in Bowlby’s (1973, 1980, 1982) concepts and studies on how indi- viduals form and use relational bonds to cope with separations and loss, it has grown into a dominant developmental and relational theory with a strong empirical base. As with many promising ideas, attachment theory has been embraced by therapists and applied to clinical settings (Berlin, Ziv, Amaya-Jackson, & Green- berg, 2005; Hughes, 2004; Fonagy, Gergely, Jurist, & Target, 2002; Lieberman & van Horn, 2008; Oppenheim & Goldsmith, 2007; Slade, 2004; Wallin, 2007; Zeanah, Berlin, & Boris, 2009). Many of those interventions are creative and useful and rest on solid theory and research, but some derive from tenuous assump- tions, or poorly translate research and/or theory into practice (see Chaffin et al., 2006; Zeanah et al., 2009 for reviews). Adaptation of research-based assessment techniques to clinical settings re- quires clarity regarding the difficulties insufficient attachments engender, the exact nature of attachment-based interventions, and how to combine such interventions with other therapeutic foci and methods. In addition, studies of normative development do not directly translate into knowledge about how best to alter poor attachments, how to form new ones later in life, or how attach- ments interact with many other aspects of development. This article looks at the significant role that attachment can play in therapy with children and parents by considering the basic tenets of attachment theory, how those principles have been and can be applied to assessments and interventions for various aged individ- uals, and the limitations of current constructs and interventions. Attachment Theory According to Bowlby (1973, 1980), attachments between chil- dren and caretakers first form in infancy from the child’s need for nurturance, comfort, and protection. To receive adequate care, infants and young children require closeness to caregivers and they establish various strategies for maintaining proximity and eliciting care and protection. Those strategies derive from the child’s per- ception of the caregiver’s availability and what works to maximize that availability. As children age and require less proximity, they continue to turn to their attachment figures when in distress or when facing challenges. When children feel secure in the avail- ability of attachment figures, they feel confident to explore. In this way, the attachment system regulates both exploratory and prox- imity needs (Mikulincer & Shaver, 2007). Through those experi- ences, children develop an internal representation or internal work- ing model (IWM) of the care and protection they have received, which provides a similar regulating and self-comforting role. Attachment Patterns Over the past few decades, researchers have delineated and elaborated four basic attachment styles: secure, anxious-avoidant, anxious-ambivalent, and disorganized (Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1990). Children may also show more than one style toward the same or different caregivers (Cowan & Cowan, 2007), although they often have a more gen- eralized dominant attachment style. Studies find that most children in western societies show a preference for a single attachment figure and that later relationships often match the level of security of that original bond (Kobak, Rosenthal, & Serwick, 2005). This article was published Online First February 11, 2013. Thanks to Sally Popper and the anonymous reviewers for their helpful comments on this paper. Correspondence concerning this article should be addressed to Karen Zilberstein, 8 Trumbull Road, #205, Northampton, MA 01060. E-mail: ekaren@me.com This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Psychotherapy © 2013 American Psychological Association 2014, Vol. 51, No. 1, 93–103 0033-3204/14/$12.00 DOI: 10.1037/a0030930 93