Pastoral Counseling Implications of Childhood Reactive Attachment Disorder And Adult Relationship Bonding Difficulties

By: Mac Partlow, MA/ABS
white paper on "Childhood Reactive Attachment Disorder And Adult Relationship Bonding Difficulties" in relation to pastoral counseling

This paper is designed to explore what would be the common psychopathology of a subgroup in my private practice population. This group all share common multi-axial traits. The goal is to investigate the most likely psychopathologies to possibly establish further axial diagnosis. One client, representative of all the common denominators will be discussed.
The structure of this paper will be divided into two parts; a retrospective, hypothetical childhood diagnosis followed by a current diagnosis. In addition, it will be important to note in each section what the implications are in terms of pastoral counseling. After developing an outcome, a treatment strategy would be devised that addresses the systemic needs of this population including pertinent concerns and interventions appropriate for pastoral counseling.


The purpose of this paper is to examine a sub-group in my practice of ten clients who share similarities with each other. First, one client history was selected as most representative of the entire group. A short descriptive history on this client will be presented. Secondly, points of commonality in terms of multi-axial diagnosis will be enumerated. In the third section, the representative client will be studied in view of the most plausible hypothetical diagnosis. In the fourth section, the most common diagnosis ruled in for initially deferred axis will be theoretically examined. The fifth section will contain an integrated multi-systems examination will be made. Lastly, some theoretical approaches that have a documented pastoral counseling application to the diagnosis will be enunciated.


A total of ten cases were eligible for this paper. This group was evaluated in terms of a balance between points of axial similarity and unique personal identifiers because of the need for both brevity and specificity in this paper, one case, selected for particular examination, was the most representative for the entire group of ten.

Common Features

I made it a point to refer each of the clients to a very well known and respected local psychiatrist. Dr. Roys did a complete psychological evaluation on each client and provided me with clinical notes including assessment and diagnosis. He also initiated medication management for depression. The common data a collected from client reports included the following. There is a consistency to the DSM-IV multi-axial diagnoses I received back as part of his notes. Axis I was generally diagnosed as: Major Depression, Recurrent, and Moderate. Axis II and III were, of course, deferred. Axis IV: Social Isolation. Axis V GAF (current) was usually around 50 with the highest in the last six months as 65.
Universally, these individuals came from families in which the parents were emotionally unavailable to their children. Some came from large families in which they were the youngest and were more often parented by older siblings than by their actual parents, Another similarity is that almost all of these clients came from families in which one or both the parents were often teachers or similar professionals in the social services.

Another apparent trait is that all of these clients demonstrate adequate to good adult functioning skills in terms of employment and daily living skills. The common exception is the absence of any history of a stable, viable relationship or similar close relationship. This is the premier issue that bothers all of them the most. They all tend to be very open and cooperative to exploring the issue and trying means to address the situation. However, they all tend not to be able to follow through on behavioral homework experiments to address the issue. Lastly, all of these clients had one or more siblings that either had failed relationships, no history of relationships, and a shared history of depression and, in one case, a sibling who committed suicide because of their social isolation.

Unique Identifiers

Christopher is a 44 year old gay white gay male, who had had problems with recurring depressions for several years. He is one of the oldest clients in my practice. We began to work together in November of 1994. What lead him to contact me was that he had been having problems with recurring depressions for several years. He had been having a great deal of difficult in the last two weeks with despondency, increased anxiety, impaired concentration, lack of energy, decreased appetite and episodic severe insomnia. He has been responding well to counseling. His review of systems is negative except for occasional heartburn for which he takes PRN Tagamet. He seldom drinks, and denies the use of nicotine or recreational drugs. He has no allergies at this time.

Christopher is generally neatly dressed and usually sits in a slumped posture. He is generally cheerful but can evoke a sad, tired or depressed moments. When questioned about these moments, he generally either professes to not being aware of them or these moods having any conscious significance to him. Eye contact is generally good and general body movements are within normal limits. Speech is usually normal in both amplitude and modulation. His sensorium is generally alert and his perception with normal perceptions.
His behavior in sessions tends to be pleasant and cooperative but with an intermittent negativistic attitudes. In our work, we have come to identify these negativistic or cynical moods as defense mechanisms from feeling too deeply. He is oriented with congruent mood and average to above average intellectual functioning. Judgment is good and thought content generally organized and of a logical process. He shows no present evidence of being at risk for either suicidal or homicidal behaviors.

Christopher is the third of four children. His older brother died of suicide in 1997. A 47 year old sister, also with a moderate history of depression recently left a long term, unsatisfactory marriage and has since remarried. He has been chronically depressed and taking Serezone, 300 milligrams. In addition he has a PRN prescription for Halcyon 0.25 milligrams, No. 4 to use as need to regulate his sleep pattern. On mental status examination, Christopher presents as a generally pleasant, stocky male with a ruddy complexion.
Christopher is moderately high functioning, professionally, with an MPA and is employed as a senior evaluator for a federal agency. He is in regular communication with his family and has two to three good, long term friends. He regularly attends St. James Cathedral where he has involvement in the liturgical life of the parish including the RCI program. He works out two to three times a week with a personal trainer and has done so for several years. He has had involvement with other clubs and organizations although none at the present time. He has dated intermittently during the entire time we have worked together and has had a few short-term relationships, none of which have lasted longer than six months.

Presently, Christopher demonstrates a continual low-grade lethargy. He is able to be motivated to do the minimum in his personal and professional life but generally nothing beyond that. Through therapy, what we have noticed are some defenses that not only keep others at an emotional distance but also tend to "cap" his ability to achieve, less in his professional life, but more in his personal life. While the excess weight is one defense, it is by no means that most significant. Generally, we have noticed that when a relationship reaches a significant level of emotional intensity, an acerbic personality trait interjects itself which generally causes the relationship to cool.


Axis II Analysis; Hypothetically Historical
Because there is no scientifically documentable information on these individuals from their childhood, a hypothetically historical retrospective analysis will be done. Since each of these clients are quite clear that there was no overt physical or sexual abuse in their own childhood histories, nor, to the best of their knowledge, the histories of their siblings, I focused on statements that alluded to benign neglect.

My motivation for exploring this possible cause arose out of a comment Chris made to me while we were exploring his experience of his family of origin. The comment he made to me in describing his experience of his parents, both of whom were teachers was that; "it was not so much that they parented me, it felt more like they 'administered' to me. They always made sure I had everything that I needed physically but that was the extent of our relationship." Upon further discussion, it became clear, that his father tended to be largely absent from the family on all levels. Furthermore, his mother clearly demonstrated distinctly narcissistic qualities as everything, in the end, was usually about her.

This tells me that while parental benign neglect is a symptom of the etiology but not the actual scientifically documentable cause itself. This being said, what I did discover however was the connection between benign neglect and attachment disorders. What became clear is that the relevant connection between neglect and the ability to form emotional attachments clearly have their roots in the pioneering work by M.D. Ainsworth and colleagues in their 1978 article; Patterns of attachment: A psychological study of the strange situation (Ainsworth, Blehar, Waters,& Wall, 1978) In it,Ainsworth and her associates demonstrated the connection between nurturance and early personality formation. They constructed an experiment entitled "The Strange Situation";

The "strange situation" is a laboratory procedure used to assess infant attachment style. The procedure consists of the following eight episodes (Connell & Goldsmith, 1982; Ainsworth, Blehar, Waters, & Wall, 1978).

  1. Parent and infant are introduced to the experimental room.
  2. Parent and infant are alone. Parent does not participate while infant explores.
  3. Stranger enters, converses with parent, then approaches infant. Parent leaves inconspicuously.
  4. First separation episode: Stranger's behavior is geared to that of infant.
  5. First reunion episode: Parent greets and comforts infant, then leaves again.
  6. Second separation episode: Infant is alone.
  7. Continuation of second separation episode: Stranger enters and gears behavior to that of infant.
  8. Second reunion episode: Parent enters, greets infant, and picks up infant; stranger leaves inconspicuously.

The infant's behavior upon the parent's return is the basis for classifying the infant into one of three attachment categories.
Secure infants either seek proximity or contact or else greet the parent at a distance with a smile or wave.
Avoidant infants avoid the parent.
Resistant / ambivalent infants either passively or actively show hostility toward the parent.(Ainsworth, Blehar, Waters, & Wall, 1978)
In the case of Christopher, and again, as a representation of the larger group, he demonstrates this resistant/ambivalent mode of functioning as a relationship begins to mature and gain in emotional intensity. The DSM-IV-TR and ICD-10 both define reactive attachment disorder as;
ICD-10 describes reactive attachment disorder of childhood, known as RAD, and disinhibited attachment disorder , less well known as DAD. DSM-IV-TR also describes reactive attachment disorder of infancy or early childhood divided into two subtypes, inhibited type and disinhibited type, both known as RAD. The two classifications are
similar, and both include:

  1. markedly disturbed and developmentally inappropriate social relatedness in most contexts,
  2. the disturbance is not accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder ;
  3. onset before five years of age;
  4. a history of significant neglect ;
  5. an implicit lack of identifiable, preferred attachment figure.

ICD-10 states in relation to the inhibited form that the syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. DSM states there must be a history of "pathogenic care" defined as persistent disregard of the child's basic emotional or physical needs or repeated changes in primary caregiver that prevents the formation of a discriminatory or selective attachment that is presumed to account for the disorder. For this reason, part of the diagnosis is the child's history of care rather than observation of symptoms. In DSM-IV-TR the inhibited form is described as: Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hyper vigilant, or highly ambivalent and contradictory responses (e.g. the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness)", (hyper vigilance while keeping an impassive and still demeanor).
Such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain "proximity", an essential element of attachment behavior. The disinhibited form shows: Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures).(American Psychiatric Association, 2000)
Axis II Analysis: Current

Attachment theory provides not only a framework for understanding emotional reactions in infants, but also a framework for understanding love, loneliness, and grief in adults. Attachment styles in adults are thought to stem directly from the working models (or mental models) of oneself and others that were developed during infancy and childhood. Ainsworth's three-fold taxonomy of attachment styles has been translated into terms of adult romantic relationships as follows (Hazan & Shaver , 1987).
Secure adults find it relatively easy to get close to others and are comfortable depending on others and having others depend on them. Secure adults don't often worry about being abandoned or about someone getting too close to them.
Avoidant adults are somewhat uncomfortable being close to others; they find it difficult to trust others completely, difficult to allow themselves to depend on others. Avoidant adults are nervous when anyone gets too close, and often, love partners want them to be more intimate than they feel comfortable being.
Anxious / ambivalent adults find that others are reluctant to get as close as they would like. Anxious / ambivalent adults often worry that their partner doesn't really love them or won't want to stay with them. Anxious / ambivalent adults want to merge completely with another person, and this desire sometimes scares people away.
Emotional/Psychological concerns are more central to treatment modalities. Given the presence of any number of ego-dystonic pathogenic belief systems, a considerable amount of attention and effort must be given both to correcting these belief systems as well as re-parenting and re-bonding issues.
Corrective Attachment Therapy is based in family systems, trauma resolution and communication work. In his family systems work, Bowlby (1988) expressed the very characteristics of treatment that Corrective Attachment Therapy encompasses: the history of the adult's experiences as a child; their relationship / attachment to their parents; the type of parent they had; the communication experienced; and their experiences and capabilities with eye contact. Doyle et al. (2000) predicted the parent / child to adult patterns uniquely with both mother and father, based on the parents' attachment style. Hendrick et al., (1994) had looked at much the same patterns. Many other writers and researchers have looked at the exploration and gathering of information concerning attachment patterns in adult relationships. This research found that the securely attached did better in relationships than the insecurely attached before treatment and that after treatment there was little difference overall between the groups. (Coster, 2004)

Pastoral Counseling Issues

In terms of spiritual/pastoral issues, a phenomenon I have noticed in my years of counseling is that generally how a client perceives their parents, and, in particular their father will be fairly consistently reflected in how they perceive the divine. This is largely echoed by Michelle A Schottenbauer in the Journal of American Pastoral Counseling;
"Traditional mental health models have frequently asserted that religious participation among those individuals with severe mental disorders is either harmful or a manifestation of their illness. Newer research, however, has found that this is not always the case. The current study examined the relationship between attachment states of mind and religious participation among a sample of consumers diagnosed with severe mental illness at a community mental health agency. We found a correspondence between attachment states of mind and participation in religious activities. Specifically, consumers who preferred interpersonal closeness with others reported a higher frequency of prayer, church service attendance, and scripture reading than those who preferred interpersonal distance. Our results suggest that people who prefer a particular interpersonal distance from humans also maintain a similar relationship with their God-object". (Schottenbauer, Fallot, & Tyrrell, 2006)
One of the aspects I would work with clients around is helping them learn to "humanize" the Divine. Again, certainly working within an object-relations framework with some cognitive-behavioral "homework" assignments, I would help them see how our therapeutic relationship could be a pale shadow of what their spiritual relationship could be with the divine a la Carl Rogers?
In the case of Christopher, what we have been doing is working primarily on his social circle and thereby working on his participation in his religious community. We have identified "triggers" that occur for him in interpersonal relationships. One of these triggers is, of course, when he notices that he is becoming either very self conscious or too acerbic in relationship to someone else. The strategy that we have is that he will allow himself to terminate the interaction with the other person but also arranging a continuation of their interaction at a specified future date and time. He then brings up the interaction in our therapy sessions. We view in detail just what he experienced not only inter-personally but also intra-personally. From this, we construct a list of potential pathogenic belief systems that were most likely operant during the session. The purpose of this activity is to identify "points of anxiety" in relational dynamics, practice behaviors that would desensitize the client in an emotionally safe environment such as with his therapist. Finally, to reengage the person that represents a more emotionally loaded relationship and implement relating through those, now desensitized, points of anxiety.

Works Cited

Ainsworth, M. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, New Jersey: Erlbaum.
American Psychiatric Association. (2000). Diagnostic Criteria for 313.89 Reactive Attachment Disorder of Infancy or Early Childhood. In M. M. First (Ed.), Diagnostic and Statistical Manual of Mental Disorders Text Revision (Fourth Edition ed., pp. 127-130). Arlington, Virginia: R.R. Donnelley & Sons Co.
Coster, P. ,. (2004). Adult Treatment Outcome Research. Retrieved February 20, 2008, from Evergreen Psychotherapy Center Attachment and Treatment Training Institute:
Eriksson, E. (1950). Childhood and Society.
Glenn, P. M., Jaffe, P. J., & Segal, P. J. (2007, January first). http://www.healingresources.infoRetrieved February 19, 2008, from Healing Resources.Info:
Hazen, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology , 52, 511-524.
Kaen, R. (1994). Becoming attached: First relationships and how they shape our capacity to love. . New York, New York: Oxford University Press.
Schottenbauer, M. A., Fallot, R. D., & Tyrrell, C. L. (2006). Attachment, well-being, and religious participation among people with severe mental disorders. American journal of pastoral counseling , Volume 8 Page 13.