Paul Valent

Paul Valent

Consultant liaison psychiatrist, psychotherapist, traumatologist,
Co-founder and past president Australasian Society for Traumatic Stress Studies,

Attachment: Back to Basics

This paper presents the essential features of the survival strategy Attachment: its biological, psychological and social features, adaptive and maladaptive manifestations, and treatment for it s dysfunctions.

Back to Basics : Attachment Trauma and Fulfilment

Lighthouse Foundation

MCG 5th March 2015

###Powerpoint 1 Back to Basics: Attachment Trauma and Fulfillment ###

Thank you very much. So much of what we have been talking about goes back to problems of attachment, separation, and not belonging.

Attachment is a basic life-promoting instinct that can provide the greatest human contentments, but can also be the source of intense human suffering. Attachment pervades our lives for better or for worse.

I want to explore with you today attachment from its biopsychosocial roots to its widest spiritual and cultural radiations.


Attachment evolved with parental care about 180 million years ago. It is present in all mammals and birds and is the infant’s contribution to the proximity required for caretaking. The opposite of attachment is separation. The separation call may be the earliest mammalian vocalisation.

###Powerpont 2 Picture###

Attachment is especially important in humans because of our species’ prolonged infantile vulnerability.

However, Attachment can occur in adults as well, for instance when in a disaster a victim develops a strong attachment bond to his or her rescuer.

Attachment is an intense instinct. It is a stronger drive than hunger. This makes sense, as it is the attachment person who provides food and protection. The process of attachment is through imprinting, like in ducklings that follow their mother.

Let me delineate Attachment from other intense instincts. In my view, important as it is, attachment is but one of a number of survival instincts present at birth. Other survival instincts are fight, flight, competition, and cooperation. Caretaking of infants and rescue of adults is another instinct and it joins with attachment to fulfill survival through nurture. Like Bowlby in his seminal work on Attachment and Loss, I also distinguish attachment from loss and grief. Loss and grief folllow irretrievable disruption of attachment, and require adaptation to new circumstances.

###Powerpoint 3

Aspect of attachment; Biological, Psych, Social

Biological Aspects

Healthy attachment

In spite of its importance, surprisingly little is known about the physiology of healthy attachment.


In separation opioid levels in the blood are decreased. In all species morphine, heroin and opiates diminish separation calls and separation distress. Heroin and opiates diminish separation suffering in humans. That’s no doubt one reason for the attraction of opiate drugs.

In separation distress the sympathetic nervous system activity increases. In the later passive phase of separation, heart rate and temperature are decreased, adrenocortical secretions are elevated and the immune system is depressed.

Importantly, because mothers are setting points for many physiological functions, separations adversely affect synchrony and attunements of physiological functions, and lead to later misattunements and malfunctions. For instance, immune system malfunction can lead to vulnerabilities to infections and cancer.

Psychological Aspects

Healthy attachment

Provides immense satisfactions. Being physically held against the chest of a familiar body, being psychologically held in the other’s gaze and mind, the minute by minute ministrations as well as long-term reliability and predictability provide a blissful sense of security and being cared for by a powerful and benevolent being, specially devoted to one’s well-being.

Unfortunately we have to look at the opposite picture.


Maladaptive separation causes intense distress, anxiety, fear, terror, panic and sense of helplessness.

In addition, there are specific pains that can be at least as intense as severe physical pains. I recall a bushfire victim telling me that her mother walking out of the hospital ward without having shown sympathy or having uttered a kind word was more painful than the burns she had suffered.

I want to mention four specific psychic pains of separation that can reach this inordinate intensity.

First is yearning. Like pangs of grief it comes in waves but it feels different to grief. It is a pain in the chest that swells out with a longing pull toward the absent person.

Second pain is missing. It is like part of one’s chest is scooped out and can only be replenished by the other person.

Third pain, also in the chest is emptiness. It is felt in the centre of the chest which feels as if it could crumple inward. The craving to fill the emptiness may be confused with hunger for food, but it is actually person hunger.

Fourth pain is aloneness, which overlaps with abandonment, rejection, and a sense of being cast out to die. As against inner emptiness, here the universe is empty. People describe it as “being on a raft in the middle of an ocean” or “in a space capsule alone in the universe”.

Associated with these separation pains are all the needs and cravings that result from lack of nurture. These include hunger, cold, and disrupted physiological rhythms such as sleep.

All in all, poor Attachment results in some of the most painful human feelings of deprivations and cravings alongside a sense of helplessness in a world threatening from outside and inside.

Social Aspects

Healthy Attachment

Healthy union is often depicted as being enveloped by an angel.

A patient looking back on his resuscitation after a near-fatal heart attack said, “I just concentrated on that nurse’s hand. She was like an angel, I knew that she would carry me through. I still think I owe my life to her.”

Secure closeness and nurture are marked by contentment. This is not a passive Nirvana state where all desire is extinguished. Rather, it is an active assimilation of abundant investments in oneself to zestfully fulfill one’s life.


Separation cries, voluble or silent are not answered. The space inside arms reached out is not filled. The person searches in the world to extinguish the pain. But clinging to wrong people causes more pain.

Question of Stress or Trauma

Stress is like a bent stick or bone that causes much pain and distress but the bone can spring back and come to perform its previous functions.

Trauma is like a broken bone. In trauma life-enhancing processes are irretrievably damaged. That doesn’t mean that a bone cannot repair or other functions compensate, but a scar and vulnerability of some kind will remain.

In that sense, stressful or distressing separation experiences can be relieved by a hug from a re-found well-established attachment figure.

Traumatic disruptions lead to long-term and recurrent separation responses. Hugs are still sought but they do not result in lasting satisfactions.

This leads us into the vast area of post-traumatic symptoms and dysfunctions.

###Powerpoint 4

Symptoms, Illnesses and Disorders : Biological, Psychological, Social

Symptoms, Illnesses and Disorders

Biological Aspects

Unrecognized psychic pains of yearning, missing, emptiness, and aloneness, as well as many other misattuned physiological symptoms constitute a large part of the estimated quarter to half the physical symptoms in general practice and emergency departments for which no physical cause is found, or which are even misdiagnosed as heart disease, asthma, and a variety of skin and digestive disorders.

A compromised immune system leads to increased susceptibility to infections, allergies, autoimmune diseases, diabetes and cancers. By the way, these are the very illnesses that contribute to higher mortality rates among the indigenous population, many of whom suffered early attachment traumas.

Severe social and emotional deprivation especially in infants is like deprivation of vital survival elements. Children’s brains may fail to develop, they fail to thrive and may even die.

Psychological Dysfunctions

Terror, yearning, missing, emptiness, and aloneness manifest in different combinations. Separation anxiety, fear of the dark, being alone, being with strangers, being outside the house (agoraphobia) are common consequences of insecure attachment. The various fears, emotions, and the ways of dealing with them are often misdiagnosed as depression, anxiety disorder, or dependent, histrionic, avoidant and borderline personality disorders.

Dissociation of emotions may lead to a sense of emotional deadness, not being oneself, and alienation. This is when depression is likely to be diagnosed.

Social Dysfunctions

Children manifest attachment disorders through clinging, school refusal, bedwetting and demanding and oppositional behaviour.

Adults may seek relief in food, alcohol, drugs, work, relationships, sexual liaisons, and pregnancy.

They may develop various personality styles in relation to others. They may be preoccupied and anxious whether the other person likes them or will leave them. They may deny their inner needs and avoid relationships altogether. They may crave, yet fear, mistrust, and avoid intimate relationships. They may make others dependent on themselves. Men may dominate women, extract care from them, and make them dependent on themselves financially and through threat of violence. In addition, women may not be able to tear themselves away from inappropriate relationships.

Here is an example of the dynamics:

A 24-year-old woman took an overdose when her abusive boyfriend, himself a product of numerous foster homes, threatened to leave her. The threat produced an intolerable pain, a huge chasm in her chest that demanded to be filled. This pain was worse than any abuse the boyfriend meted out. A hug from her boyfriend filled the space and relieved the pain instantly. In the past only heroin had eased it.


We have considered the biopsychosocial aspect of positive and negative attachments. I briefly want to touch on ripples of attachment across the life-cycle, generations, society, and the soul.

###Powerpoint 5. Ripples of Attachment and Separation###

Ripples across the life cycle and Generations

Ripples in Society

Ripples in the “soul”

Attachment and Separation Ripples

Ripples across the life cycle and the generations

Early attachment experiences establish beneficial or harmful physical, psychological and behavioural platforms for later stations in life. Separation problems re-emerge at times of individuation challenges such as school entry, adolescence, leaving home, and losing people one depended on.

Attachment experiences are re-evoked when one’s children reach the stages of one’s own attachment challenges. Models of dealing with separations may be repeated down the generations.

Ripples in society

Successes and failures in primary attachment bonds may be replicated wherever people depend on others- in, school, employment, later families, social groups and communities. Images of parents may be reflected onto teachers, police, and leaders. Or people may attempt to make up for insufficient attachment by seeking it from later authority figures, the government, and welfare. They may join fraternities such as police and army, or gangs and cults.

Ripples in the “soul”

Attachment ripples through the human mind from basic survival to highest spiritual needs.

A well-attached child will form judgements that it is good, wanted, valuable and lovable. It will have faith in always being cared for, in its right to have its needs met. Such a child is relatively likely to develop optimistic views of its place in the scheme of things and in the universe. It will believe in justice, dignity, and values. Its life will seem to have meaning and purpose.

Unattached children may feel angry, guilty and ashamed, interpreting that their rejection was for being bad, unworthy, and unlovable. They grow into adults who feel that the world is unjust, that they themselves lack rights to demand that their needs be met. They are further ashamed for their weaknesses and helplessness.

They may compensate by being aggressive and imposing dependence, helplessness and humiliation on others.

Alternately, they may attach to institutions, ideologies and religions, even at times terrorist groups, which promise belonging and purpose. Such attachments often lead to disillusionment.

Insufficient Attachment Is Not the End

For a child poor Attachment is a catastrophe. But there are mitigating factors and reasons for hope.

###Powerpoint 6. Mitigating Factors###

Some attachment

Innate capacities


Capacity for Attachment remains

First, for children to have survived, they must have extracted some benevolence from the world, be it from their parents, substitute parents, strangers, pets, dolls, blankets, or even just fantasies.

Second, insufficient attachment does not diminish innate capacities such as in sport, craft, and the arts. Such capacities can provide respect and belonging in a group.

Third, people can find substitute Attachment figures in business, professions, politics, religions, at worst even gangs and cults. Each can provide a degree of meaning and purpose.

Fourth, hope lies in the fact that we are all hard-wired for attachment. That means that it is never too late to experience its beneficial effects. Once experienced, healthy attachment cannot be erased. It serves as a platform to build on.


###Powerpoint 7. Treatment###


Attachment Environments

Symptomatic Treatment

Specific Treatment

Treatment has a number of layers.

First is recognition. It is important to recognize the various physical, psychological, and social manifestations of attachment malfunctions and to recognise their sources.

Second is provision of healthy attachment type circumstances. The person is provided with shelter, food, warmth, company, interest, reliability, predictability, and a general caretaking environment.

Third is symptomatic treatment. Various physical, psychological, and social symptoms are relieved through medication, self-soothing exercises, education, explanation, exercise, joining clubs, interest groups, et cetera.

Fourth is specific treatment. In a trusting caretaking professional relationship the person experiences someone who cares, provides regular rhythms and routines, is empathic, reliable, and trustworthy.

In this environment people re-experience and remember their attachment traumas. The memories and current opposite experiences merge and from the new melting pot emerge new understandings and a new narrative of belonging.

People realize that they don’t need attachment experiences that they had missed out on in the past anymore.

They develop a new sense of identity, self-esteem, self-love and capacity to love others, as well as new meanings and purpose in the world.


Because humans need caretakers for a prolonged period of their childhoods, attachment is an important vehicle of survival and building of one’s person.

When parents provide the right fuel and scenery, the vehicle motors along nicely in a beautiful world. When the fuel runs out or is the wrong fuel, the vehicle may go off the road, and the world is topsy-turvy and dangerous.

To repair the vehicle we must recognise the physical, emotional and social damage and its ripples that the derailment has caused.

With proper care, it is possible to come out of the damaged vehicle and to continue the journey.

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