Which attachment style is characterized by an infants inconsistent reactions to the caregivers departure and return?

Predicting Dependency from Attachment

Attachment researchers such as Sroufe believe that securely attached children will actually come to be less dependent than children who have insecure attachment relationships. For example, Sroufe and colleagues found that children who had been securely attached to their mothers were rated by their teachers as lower in dependency. Children who had avoidant or anxious-ambivalent attachment relationships with their mothers during infancy were rated by their teachers as overdependent. Consistent with psychoanalytic theory, such dependence is maladaptive in a number of ways. For example, being highly dependent on teachers’ approval and attention may interfere with the opportunities where children can develop friendships with peers. In contrast, children who have secure relationships are effective in seeking contact so that they can quickly return to their peers and resume playing. The contact with teachers thus supports peer relationships. These children are also more involved in peer groups and are better liked by their peers and teachers. As such, the key point here is that secure children are more effective in expressing dependency behavior.

The implication of the attachment theory for the development of independence and autonomy goes beyond infancy. According to attachment theory infants who are securely attached have developed a confident expectation toward their mothers, which will eventually be generalized to the view of other people; that is, they develop an ‘internal working model’ of themselves and the world around them. As such, these babies will become more independent compared to other babies who do not have such confident expectations.

Attachment Style and Psychological Disorder

According to the DSM-5 (American Psychiatric Association, 2013), reactive attachment disorder is characterized by markedly disturbed patterns of attachment behaviors resulting from the inability or failure to develop secure attachment with caregivers. A review investigating the relationship between early parental bonding and psychiatric symptoms in adulthood found that neglectful or overprotective parenting increase the risk for developing anxiety, depression, and self-esteem issues in adulthood (Lima, Mello, & de Jesus Mari, 2010). Similarly, in a sample of Jewish settlers, Mikulincer, Horesh, Eilati, and Kotler (1999) found that anxious-ambivalent attachment was significantly positively related to greater psychiatric symptoms (e.g., somatization, obsessive-compulsive problems, psychoticism) and posttraumatic stress symptoms (e.g., intrusions, avoidance), while secure attachment was inversely related to such symptoms. Indeed, insecure attachment has been shown to be associated with a multitude of mental health issues, including depression, anxiety, and personality disorders (for a review, see Shorey & Snyder, 2006).

To the extent that close interpersonal attachments buffer anxiety, one would expect attachment style to influence coping with stressful and traumatic experiences. In a study investigating whether activating the attachment system would buffer intrusive memories following exposure to traumatic content, Bryant and Foord (2016) found that when subliminally primed with attachment-related images prior to traumatic (e.g., bloody or dismembered bodies) or neutral images, individuals high in avoidant attachment reported more intrusive memories. Interestingly, they found that for participants high in anxious attachment, subliminally priming attachment images led to decreased recall of both traumatic and neutral images, thus suggesting that the hyperactivation of the attachment system that occurs for anxious individuals may impede memory formation—one of the central dysfunctions involved in the development and chronicity of PTSD (for a review, see Brewin, 2011). Indeed, greater activation of areas of the brain associated with social rejection, sadness, subjective distress of pain, and neuroticism, and greater deactivation in brain areas associated with emotion regulation, as well as greater access to negative memories, have been found in anxiously attached individuals following negative primes involving romantic partners (Gillath, Bunge, Shaver, Wendelken, & Mikulincer, 2005).

It is clear from the research discussed thus far that myriad forms of psychological dysfunction can be connected to the collapse of anxiety-buffering mechanisms aimed at protecting individuals from the problem of death. Ineffective anxiety-buffer functioning produces compensatory efforts that promote difficulties in daily functioning, and over time, can manifest in psychopathology, leaving individuals struggling, and often failing to keep death thoughts at bay. We turn now to a discussion of the dynamic impact of traumas that occur later in life, after one’s anxiety-buffers are relatively well developed.

D Mediator model #3: parental gate-keeping

Parental gate-keeping refers to the extent to which parents restrict versus facilitate their children's socializing outside of the parent–child relationship (e.g., a parent who prevents a child from going to play at a friend's house). Parental gate-keeping can occur through both verbal and nonverbal means. With regard to the ParentAttachment → ChildSIP pathway, a parent who possesses a secure-autonomous state of mind with respect to attachment or a secure attachment style may facilitate the child's exploration of the social environment, and such exploration may benefit the child's social information processing (e.g., interaction with peers may facilitate learning how to perceive emotions and intentions of peers accurately). An insecure parent, however, may implicitly or explicitly restrict a child from engaging in extrafamilial socialization events that could ultimately affect the child's information processing. A parent who possesses an ambivalent attachment style, for example, could prevent the child from forming new social connections because these types of parents may be (generally) anxious about whether individuals will meet their attachment-related needs. This lack of social experience may impair the child's information processing of peer-related information, such that the child may have more difficulty encoding social cues accurately.

With regard to the ParentSIP → ChildAttachment pathway, a parent's information processing may affect whether and how this caregiver allows a child to engage in independent exploration and/or participate in extrafamilial socialization events. A parent who views the world negatively (e.g., a parent who views the outside world as a dangerous and/or frightening place) or perceives other persons in a nonpositive (or perhaps hostile) light may restrict the child's natural desires for exploration, which could ultimately affect the child's attachment security. Grossmann, Grossmann, Kindler, and Zimmermann (2008), for example, noted that security stems in part from “a parent's willingness and ability to support their child's exploration sensitively and appropriately provide the child with realistic self-confidence in his or her competence in new situations” (p. 859; see also Ainsworth et al., 1978). Indeed, if parents do not give their children the freedom to engage in new experiences and meet new individuals, their children may come to believe that attachment figures are not helpful and not understanding of their personal wishes; as such children mature, they may also not feel “trusted” by attachment figures to make correct decisions outside of the family context. Such feelings of not being helped, not being understood, and/or not being trusted may, in turn, be detrimental to the child's attachment security. However, when parents view the world and persons within it positively and give children the freedom to explore the environment, these children will likely feel understood and trusted, feelings that will likely contribute to their attachment security.

Research Supporting the IWM Correspondence Hypothesis

People having varying attachment styles (secure, anxious/ambivalent, and avoidant), resulting in varying IWMs, which would suggest they would have varying religious/spiritual attachments. Main’s disorganized style as related to religion is reviewed in the next section.

Indirect evidence of the IWM correspondence hypothesis is that in cultures in which parenting is more frequently warm and loving, God is perceived as more benevolent (Lambert, Triandis, & Wolf, 1959). Whereas in cultures distinguished by harsh and rejecting parenting, God was perceived as less benevolent and loving.

People in secure romantic relationships are more likely to report God as being loving and benevolent. Whereas people in avoidant romantic relationships are more likely to be agnostic or atheists (Byrd & Boe, 2000; Granqvist & Hagekull, 2000, 2003; Kirkpatrick, 1998). Secure participants reported greater religious commitment and more positive images of God compared to insecure people (Kirkpatrick & Shaver, 1992). Respondents in avoidant romantic relationships were most likely to be agnostic. In a unique study of 216 Christian theology students, there was a strong positive relationship between being securely attached and overall spiritual maturity (TenElshof & Furrow, 2000).

The frequency of religious conversions would be expected to be higher for the ambivalent insecures because they seek security during times of duress. Anxious/ambivalent women were more likely, compared to secure and avoidant women, to report a religious conversion over a four-year period (Kirkpatrick, 1997). Utilizing Bartholomew’s (Bartholomew & Horowitz, 1991) four-category self-classification measure of anxious/ambivalent attachment (negative model of self and positive model of others) also reported more religious change over a four-month span compared to the other attachment styles (Kirkpatrick, 1998).

A study directly assessed adults ratings of their relationships with their parents, God, and themselves, in regard to closeness, nurturing, power, and punishing/judging (Dickie, Ajega, Kobylak, & Nixon, 2006). Women who perceived their parents as a model for nurturance and power also envisioned God as nurturing and felt close to God. Whereas men, via the nurturance and discipline of their mothers, were more likely to perceive God as nurturing, to feel close to God, and to be more religious. The adults who rated their parents as punishing/judging also perceived God as punishing/judging. Future studies on this last group, by including a measure of right wing authoritarianism (RWA, Chapter 7, Fromm), may help to further understand RWA. The IWM of the infants, based on their infant relationship with parents, does partially reflect peoples’ relationship with God.

It would be expected that, based on the IWM correspondence hypothesis, religious people of the varying attachments would also vary in regard to how they seek proximity to God or a secure attachment base to explore. Specifically, do the various attachments styles vary in the type of prayer to seek the proximity or secure base of the attachment figure of God? In a study of Midwestern university students who were overwhelmingly Christian (58% Protestant and 31% Catholic; Byrd & Boe, 2001), the measure of attachment was the Relationship Scales Questionnaire (Griffin & Bartholomew, 1994a, 1994b). The authors of the study used this measure to tap the anxiety dimension (anxiety about abandonment) and an avoidance dimension (avoidance of closeness to others). They also included a measure of current stress in their lives, Student Stress scale (Insel & Roth, 1991). The avoidant respondents were significantly less likely to use colloquial prayers (e.g., “How often do you talk with God in your own words?”), and were less likely to use meditative prayer (e.g., “How often do you spend time just quietly thinking about God?”). The anxiety participants were more likely to practice a form of petitionary or materialistic help-seeking prayer (e.g., “How often do you ask God for material things you may need?”).

In a study that developed an attachment-to-God measure, avoidant attachment to God was inversely correlated with loving God images, Christian orthodoxy, intrinsic religious orientation, agreeableness, and religious symbolic immortality (Rowatt & Kirkpatrick, 2002). Anxious/ambivalent attachment to God was positively associated with extrinsic religious orientation, negative affect, and neuroticism.

In four studies of Israeli Jewish students, they found consistent support for the IWM correspondence hypothesis (Granqvist et al., 2012). Based on a current relationships measure of attachment, the anxiety participants endorsed more attachment anxiety items toward God (e.g., “I worry about being rejected or abandoned by God”). Whereas, the avoidant participants endorsed more avoidant items toward God (e.g., “God seems to have little or no interest in my personal problems”). The avoidant participants were also significantly less likely to appraise God as loving.

In a previous section, two articles were cited which support that people seek God under duress. These studies also support the IWM correspondence hypothesis. One study was with Christian participants (Birgegard and Granqvist, 2004) and the second study was with Jewish participants (Granqvist et al., 2012). In both studies, the participants were subliminally primed with varying levels of distress, and their reaction time of words associated with a relationship to God was the dependent variable. They found overall, as noted in the previous activating section, that religious people respond faster under distress to the subsequent God-related terms compared to the neutral terms. Their hypothesis that avoidant participants would have slower response time was supported. These findings provide evidence that under stressful conditions, religious people automatically, or unconsciously, turn to God; however, perhaps the avoidant people responded slower because they deactivated their attachment system and were more reliant on a conscious appraisal. As further evidence that secure individuals develop an IWM that provides a secure base to explore, they found the secure participants, following God priming, had faster reaction times when followed by positive words. Whereas avoidant participants had faster reaction times when the God prime was followed by negative words. This last finding was stronger particularly for highly religious avoidant people. Finally, they also found evidence that secure participants had access to an emotional IWM secure base compared to the avoidant participants.

Summarizing, given the relatively recent involvement of research on attachment theory and religion, there are numerous studies which support the social correspondence hypothesis, compensation hypothesis, and IWM correspondence hypothesis.

II. Theoretical Basis

IPT is grounded in attachment theory, which as described by Bowlby among others, rests on the premise that people have an instinctual and biological drive to attach to one another. When crises occur, individuals seek reassurance and care from those important to them. Interpersonal communication is intrinsic to this process, and individuals who cannot effectively ask for care, and consequently cannot obtain the physical and psychological care they need, will suffer as a result. When interpersonal support is insufficient or lacking during times of stress, individuals are less able to deal with crises and are more prone to develop psychiatric symptoms.

Bowlby described three different types of attachment styles that drive interpersonal behavior. Secure attachment describes individuals who are able to both give and receive care, and are relatively secure that care will be provided when it is needed. Because securely attached individuals are able to communicate their needs effectively, and because they are able to provide care for others, they typically have good social support networks. Thus they are relatively protected from developing problems when faced with stressors.

Anxious ambivalent attachment, in contrast, is a style in which individuals behave as if they are never sure that their attachment needs will be met. Because of this, such individuals believe that care must be sought constantly. Such individuals often lack the capacity to care for others, since their concern about getting their own attachment needs met outweighs all other concerns. Consequently, they have a relatively poor social support network, which in combination with their difficulties in enlisting help, leave them quite vulnerable to interpersonal stressors.

Individuals with anxious avoidant attachment typically behave as if care will not be provided by others in any circumstances. As a result, they avoid becoming close to others. The paucity of their social connections, along with their tendency to avoid asking for help during times of crises, leaves these individuals quite prone to difficulties.

In essence, attachment theory states that those individuals with less secure attachments are more likely to develop psychiatric symptoms and interpersonal problems during times of stress. A persistent belief that care must be constantly demanded from others, or that care will not be provided by others, typically leads insecurely attached individuals to have more difficulty in asking for and maintaining social support during times of crisis. Severe disruptions of important attachment relationships, such as the death of a significant other, also lead to an increased vulnerability to psychiatric symptoms.

Interpersonal psychotherapy also follows the biopsychosocial model of psychiatric illness, resting on the premise that psychiatric and interpersonal difficulties result from a combination of interpersonal and biological factors. Individuals with a genetic predisposition are more likely to become ill when stressed interpersonally On this foundation rests the individual's temperament, personality traits, and early life experiences, which in turn are reflected in a particular attachment style. The attachment style may be more or less adaptive, and has effects on the person's current social support network and his or her ability to enlist the support of significant others. Interpersonal functioning is determined by the severity of current stressors in the context of this social support.

Interpersonal psychotherapy is therefore designed to treat psychiatric symptoms by focusing specifically on patients’ primary interpersonal relationships, particularly in the problem areas of grief, interpersonal disputes, role transitions, and interpersonal sensitivity This is done by helping the individual to recognize and modify his or her communication patterns, which has a threefold effect. First, it leads to more effective problem solving, as conflicts can be more directly addressed. Second, it improves the patient's social support; communicating in a way to which others can more readily respond will more effectively meet the patient's attachment needs. Third, these improvements in communication and in conflictual relationships, and improved social support, help resolve the interpersonal crisis and result in symptom resolution.

1.1 Historical, Cultural, and Biological Context

Attachment is not an invention of modern times; attachment behavior is not restricted to modern, industrialized countries and cultures, and it is not an exclusively human characteristic. About 3,000 years ago, Homer had already described an example of infant attachment behavior to mother, father, and professional caregiver. In the famous Iliad, the Trojan hero Hector returns from the battlefield to his family, smeared with mud and blood of the previous fights. Achilles is waiting for him to revenge earlier assaults on the Greek warriors, and he will defeat Hector in an atrocious fight. Hector wants to spend the remaining time with his wife, Andromache and his son, Skamander who is in the arms of his ‘nanny.’ Hector scares Skamander with his imposing helmet and with the traces of the earlier battle. In response to the reunion with Hector, Skamander seeks close physical contact with his nanny because he does not recognize his father. Hector notices the signs of fear that his son displays, takes off his helmet, and starts to play. His sensitive interactions stimulate Skamander to smile and play with his father; Andromache looks at this peaceful and moving scene in tears as she foresees the death of her husband in the fight with Achilles. After a while Hector carries his child to Andromache who cuddles him, and takes leave. Mother and son will never meet with their husband and father again.

The empirical study of attachment did not start in a Western culture. In fact, Ainsworth's first investigation of attachment was conducted in Uganda, a former British protectorate in East Africa. Here, she discovered the now-famous tripartite classification of insecure-avoidant, secure, and insecure-ambivalent attachment relationships (see later). It was in this African culture that she also studied, for the first time, the antecedents of attachment, in particular parental sensitive responsiveness. After this path-finding field-study of attachment, the development of attachment between parents and infants in several other African cultures has been studied, for example in the Gusii, the Dogon, the Hausa, the Efe, and the !Kung San. Furthermore, cross-cultural attachment research has been carried out in China, Japan, and Indonesia, and in the unique setting of the Israeli kibbutzim. In these diverging cultures attachments seem to emerge inevitably between helpless offspring and protective parents, similar patterns of associations between antecedents and sequelae of attachment security seem to arise, and similar perceptions of the value of a secure attachment relationship for the individual, the family, and for society seem to be prevalent. Cultural diversity in the expression of attachment is, however, acknowledged. In the Gusii culture, for example, infants are accustomed to being greeted by their returning mothers with a handshake instead of a hug, and accepting or refusing the handshake can be considered indications for the security of the attachment relationship in the Gusii dyad. The patterning of attachment behaviors is independent of the specific attachment behaviors that express the children's emotions, and these patterns of attachment have been found in all cultures studied thus far. Attachment, therefore, appears to be a universal phenomenon, and attachment theory claims universal validity (Van IJzendoorn and Sagi 1999, see also Cultural Variations in Interpersonal Relationships).

Attachment has been observed in many species, and John Bowlby drew heavily on the results of ethological investigations of attachment in nonhuman primates for the construction of attachment theory. Harlow's experiments with rhesus monkey infants showed that the development of attachments is not dependent on the provision of food and, thus, the result of reinforcement schedules, but seemed to be ‘instinctive’ behavior directed at objects providing warmth and protection. Field studies of rhesus monkeys showed that in the first few months after birth the infants develop enduring and unique bonds with the mother who protects the infants against predators and other environmental dangers. Rhesus monkey infants use their mother figure as a secure base to explore the environment, and to regulate their negative emotions and stresses. This role of a secure base is fulfilled uniquely by the mother and not by other members of the group or even by relatives. Bowlby derived from these ethological findings the idea that human infants were born with an innate bias to become attached to a protective adult because the affective bond would have evolutionary advantages (see also Psychological Development: Ethological and Evolutionary Approaches). Infants may differ in the expressions of their attachment ‘needs,’ and the patterns of their attachment behavior may diverge, but, basically, every representative of the human species would show attachment behaviors. In his later work he introduced the concept of ‘inclusive fitness’ into attachment theory to take into account the parental side of the first attachment relationship. It should be noted that nonhuman primates differ widely in the emergence and display of attachment relationships between infants and mothers. For example, capuchin monkey infants do not only rely on their mothers, but also on their peers and relatives for contact comfort and protection, and their bond with the mother seems much weaker than in the case of the rhesus monkey infants. The evolution of attachment theory might have been completely different if, in the 1950s and 1960s, ethologists had studied the social relationships of capuchin instead of rhesus monkey infants (Suomi 1999).

1.14.4.6 Bowlby's Attachment Theory Model

Parenting Factors

The compensation hypothesis

Human beings have an innate need to belong, and social relationships constitute an essential source of support that facilitates psychological well-being and physical health (Cacioppo and Patrick, 2008; Seppala et al., 2013). PSRs have been long theorized to compensate for insufficient or poor-quality social relationships by offering safe, positive, and always available relational alternatives to real-life social ties. Thus, researchers have posited that individuals who wrestle with forming meaningful real-life relationships may seek out PSRs as a form of compensation for deficiencies in their social lives (i.e., the “compensation hypothesis;” Tsao, 1996; also dubbed the “social surrogacy hypothesis”, Derrick et al., 2009).

Empirical support for the compensation hypothesis is somewhat mixed. Overall, a systematic empirical review of research in this area (i.e., meta-analysis) finds no significant relationship between loneliness and PSRs (for review: Tukachinsky et al., 2020). However, this correlation may be masked by various qualifying conditions, such that the association between PSRs and loneliness may exist for some media users but not others. For example, PSRs may serve this function only under specific circumstances, such as when individuals experience a deficit in particular types of social relationships or when media provides the experience of social presence (e.g., Baek et al., 2013; Greenwood and Long, 2009; Wang et al., 2008).

Whereas research on loneliness and PSRs examine the compensation hypothesis directly (by positing that people who endure insufficient social relationships seek relationships with media figures), others examined this hypothesis more indirectly. Specifically, guided by the logic of the compensation hypothesis, researchers have postulated that individual characteristics that mark unsatisfying social relationships will predispose these people to form deeper parasocial ties. For example, extensive research has examined the association between the propensity to form PSRs and media users' attachment style. Attachment theory (Bowlby, 1969; for review: Fraley, 2002) posits that the way individuals interact with others throughout their lives hinges on their early childhood experiences with caregivers. Although the theory initially examined childhood attachment, it was later extended to adult romantic relationships (Hazan and Shaver, 1987). Several typologies have been proposed to describe attachment styles, referring to people's mental models of self and relationships (Ainsworth et al., 2015; Bartholomew and Horowitz, 1991). Across the different typologies, secure attachment entails experiencing relationships as stable and trusting. The different typologies vary in their classification of other attachment styles, but they generally identify avoidant/dismissing attachment (fear of intimacy); anxious/preoccupied attachment (fear of rejection and clinging to the relationship), and ambivalent attachment wherein individuals are torn between the desire to connect and the desire to flee from relationships. According to Stever (2013), individuals can form secondary attachment, i.e., parasocial attachment (PSA) with media figures, finding a safe harbor in that relationship. Anecdotal evidence from in-depth interviews reveals that PSAs to media personalities can offer comfort to individuals coping with grief or trauma (Stever, 2011). Some interviewees noted that these PSRs allowed them to feel in touch with romantic feelings long-buried after experiencing a tragedy or loss.

Overall, as it relates to PSRs, research suggests that people who tend to seek more interpersonal connections (i.e., individuals with secure or anxious attachment) also seek more parasocial ties (e.g., for meta-analysis see: Tukachinsky et al., 2020). These findings suggest that, typically, PSRs offer an extension of, rather than a substitution for, social ties. However, when grappling with challenges, individuals may be particularly compelled to seek them out. For instance, Bond (2021) found that people turned toward PSRs during lockdowns due to the COVID-19 pandemic. Specifically, individuals who were low in attachment anxiety, had reduced face-to-face socialization with real-life friends, and had increased mediated social engagement with those friends (i.e., Zoom, FaceTime), reported an increase in their parasocial engagement and parasocial closeness with media personalities over time. In essence, PSRs served an additive function to the support individuals received from real-life friendships. These results suggest that PSRs have the potential to enhance real-life relationships.

It appears that the social surrogacy benefits of PSRs are particularly critical for individuals who are socially isolated, lonely, or belong to a vulnerable group. For example, Bond (2018) found that PSRs intensity was positively associated with loneliness in relationally vulnerable lesbian, gay, and bisexual (LGB) adolescents, but the correlation between loneliness and PSRs was not significant in heterosexual adolescents. These findings imply that LGB adolescents may seek out LGB media personae to supplement real-life social relationships. In a different study, Woznicki et al. (2021) examined how LGBQ (lesbian, gay, bisexual, and queer) adolescents turn to PSRs for support during the COVID-19 pandemic. Against the backdrop of social isolation, lower family support led to greater loneliness, which in turn increased the teenagers' depressive symptoms. However, stronger PSRs with their favorite LGBTQ YouTubers shielded adolescents from these negative effects. Together, the results from both studies indicate that PSRs play a role in the well-being of members of marginalized groups, and perhaps particularly during times of crisis, such as the COVID-19 pandemic.

Other individuals who generally struggle to form meaningful real-life relationships may also find comfort in PSRs. For example, Tukachinsky Forster (2021) found that romantic PSRs can sometimes be used to ease back into social relationships. In in-depth interviews, women discussed their struggles with sexuality after giving birth or their reluctance to engage in new romantic relationships following a traumatic divorce or the loss of a spouse. The safe romantic PSR helped these women reconnect with their sexual and romantic selves, preparing them to re-enter the dating scene later on.

In addition to these situational factors, some personality characteristics may also predispose individuals to turn to media to fulfill their relational needs. For instance, individuals who score high on Dark Triad traits (narcissism, psychopathy, Machiavellianism) typically experience difficulty maintaining satisfying romantic relationships. Consequently, these individuals were found to report stronger romantic parasocial attachments to media figures (Liebers and Schramm, 2021).

To summarize, whether due to challenging external (i.e., social isolation) or internal (i.e., personality traits) circumstances, individuals can find relief in their PSRs. Some scholars conceptualized these effects as “social snacking,” or the temporary satisfaction that comes from interacting with a virtual other when individuals are deprived of real-life interaction (Gardner et al., 2005). Essentially, individuals may fill the void of real-life social interactions with a temporary “snack” of a PSR, which can temporarily satisfy their social needs. While PSRs cannot replace social connections, they appear to offer a viable way to supplement non-mediated social ties to address these needs.

Andrea, Lucia, and Leo

Again, let’s start by adding more information to the case. During the intake interview with Leo, he is not able to discuss his feelings about or immediately before social or performative situations in any depth beyond the fact that he doesn’t want to do them. At one point in the interview he says that he is “just a reject.” During the intake interview with Lucia and Andrea, Andrea admits that he is frequently “distracted by work” and finds it difficult to find the time and energy to focus on being a father and a husband. He also states that he finds himself struggling with a sense of shame about Leo’s behavior, saying “what’s wrong with him? Why can’t he grow up?” Lucia admits that she sometimes blames herself, explaining “maybe I was too soft with him when he was younger?” Notably, Andrea and Lucia report feeling “embarrassed” and “uncomfortable” when Leo avoids social interactions.

Andrea and Lucia’s feelings of embarrassment, discomfort, and shame around Leo’s social behavior are likely related to how they respond to Leo. Firstly, when they allow him to escape social situations, this may relieve their sense of discomfort. But also, they may attribute particular meanings to their own intense feelings, perhaps that embarrassment/discomfort/shame is “intolerable,” and if Leo also feels embarrassed in social situations, they may then derive that this is “intolerable” to him. Again, this may inadvertently reinforce his avoidance of social situations—as well as the experience of his own embarrassment and discomfort. A clear understanding of this may help Andrea and Lucia develop a different sort of relationship to their discomfort: clinicians might support them in modeling feeling embarrassed/uncomfortable and engaging in social situations anyway, such that Leo might observe, make similar attempts, and discover for himself how to engage in social approach. In addition, for Leo and Andrea, Leo’s social difficulties mean that there is something fundamentally wrong with Leo: “just a reject” or “what’s wrong with him?” This suggests that Leo’s social difficulties cannot be changed. The clinician could ensure that, throughout the intervention, social skills are framed as a skill, as something that can be learned, practiced, and improved upon not as an innate ability.

Changing the relationship of parents to aversive private events is at the heart of ACT, and clinical RFT work can be addressed using particular ACT processes. Midlevel models of ACT processes including the hexaflex and DNA-V can also be used within a case formulation process, for both the parent and the child. These models focus on ACT processes for the parent and the child and can be used in conjunction with a functional analysis of specific target behaviors, as part of a full formulation. In fact, ideally a functional analysis is performed first, and then, from the functional analysis the clinician asks which ACT processes may or may not be involved. Does the parent or child have any particular strengths in terms of ACT processes? Does the parent or child have any particular weaknesses in terms of ACT processes? This can then form the basis of setting goals around the ACT processes focused on in intervention. Again, formulation is an ongoing process. It may be the case that initially you are unsure of the role of specific ACT processes within the parent–child interactions in questions or have tentative ideas only. Such thoughts can still form part of the initial formulation with their tentative nature noted.

Let’s explore using the parent–child ACT hexaflex for the two cases earlier. Remember the parent–child ACT hexaflex looks like this:

Let’s explore each of the six processes on the hexaflex in turn for Fan and for her parents Mei Lin and Tao. You will notice that as Fan is 3 years old, her competencies in the six processes need to be understood developmentally and as emerging from within her social relationships. Considering the six ACT processes with children and adolescents is not so much about identifying deficits, but rather about considering the ways in which the child’s context including the parent–child relationship is supporting the emergence of competencies within these areas in a developmentally appropriate way.

Let’s now turn to how this may apply for the other case that we have already introduced: Leo and his parents, Andrea and Lucia. As Leo is 13, the ACT processes are more directly relevant. Yet, they still need to be understood developmentally and as emerging from Leo’s ongoing context and relationships to others.

The DNA-V model can be used in a similar way for parent and child, but this will not be explored in this book. For a full exploration of formulation using the DNA-V model we suggest you refer to The Thriving Adolescent by Louise Hayes and Joseph Ciarrochi (Hayes & Ciarrochi, 2015). The DNA-V model is outlined in Chapter 1, Introduction, of this book.