Attachment Therapy

Attachment theory in the mid-twentieth century

Inge Bretherton's 1992 history describes attachment theory as the joint work of John Bowlby (1907-1991) and Mary Ainsworth. Bowlby's interest in the link between maternal loss or deprivation and later personality development began in the 1930s. After the Second World War he headed the Children's Department at the Tavistock Clinic in London, and a report he wrote for the World Health Organization was published in 1951 as Maternal Care and Mental Health. Ainsworth joined his research unit in 1950, after a visit to Uganda where she conducted what Bretherton calls the first empirical study of infant-mother attachment patterns.

Bretherton credits Ainsworth with the idea of the attachment figure as a secure base from which an infant explores, and with the concept of maternal sensitivity to infant signals. The article is a history of a developmental theory. It does not describe a therapy protocol, so the theory itself should not be read as an endorsement of any particular treatment.

From theory to parenting programs

Interventions that draw on attachment theory generally work with the caregiver and the parent-child relationship. The 2006 report of the American Professional Society on the Abuse of Children (APSAC) Task Force summarizes a 2003 meta-analysis of more than 70 studies of early-childhood attachment interventions, which found that those that most increased parental sensitivity were also the most effective in improving children's attachment security, and that shorter, more focused interventions tended to do better than broad, long ones.

A Cochrane review dates a more recent line of work, video feedback, in which a parent is shown brief moments of interaction with the child, and its search ran to November 2018. A 2015 UK health technology assessment of parenting interventions for severe attachment problems searched to January 2012 and found 29 randomized trials of parenting interventions to improve attachment patterns.

The emergence of coercive methods

The APSAC Task Force describes a subset of practitioners who developed techniques such as holding, restraint and rebirthing for children, mostly maltreated children in foster or adoptive homes, who were described as having attachment disorders. The report does not give a founding date. It says the controversy deepened after a child died during a therapy session in 2000 and after other child deaths in homes where parents said they had followed a therapist's instructions.

The American Academy of Child and Adolescent Psychiatry (AACAP) adopted a policy statement against coercive interventions for attachment disorders in November 2003, and its Council approved a revised version in December 2022.

Two meanings of the term

The APSAC Task Force states that the terms attachment disorder, attachment problems and attachment therapy have no clear, specific or consensus definitions. In public use, among foster and adoptive parents and caseworkers, 'attachment therapy' has often meant the controversial coercive methods. The Task Force adds that those therapies do not represent the practices of all professionals who use attachment concepts as a basis for their interventions. This page therefore uses 'attachment-based' for programs grounded in the theory and 'coercive attachment therapy' for the practices that professional bodies reject.

Reactive attachment disorder and related labels

Reactive attachment disorder (RAD) is a formal diagnosis. The APSAC report, written when the fourth edition of the DSM applied, describes its core feature as severely inappropriate social relating beginning before age 5, and says a broader 'attachment disorder' was not part of any accepted classification system. AACAP's 2016 practice parameter covers RAD and disinhibited social engagement disorder, defines disordered attachment by abnormal social behavior in the context of insufficient care or social neglect, and says assessment requires direct observation of the child with primary caregivers.

Attachment-based, attachment-informed and attachment parenting

Reviews use the term attachment-based for interventions that are at least partly informed by attachment theory. The 2015 UK assessment uses 'severe attachment problems' to mean disorganized attachment patterns and attachment disorders, and the research literature measures attachment security with observational tools such as the Strange Situation Procedure and the Attachment Q-Set.

The APSAC report notes that 'attachment parenting' can mean close physical contact between mothers and newborns, which is not its subject. In the report it means parent-delivered practices similar to the coercive therapies.

Video-feedback programs

In video feedback, a practitioner shows a parent brief moments of the parent's own interaction with the child, aiming to strengthen sensitivity and responsiveness to the child's signals. One widely studied program, the Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD), combines support for sensitive responsiveness with coaching in sensitive limit setting. The Cochrane review included trials in which parents faced difficulties such as a child's deafness or prematurity, or parental depression.

Attachment and Biobehavioral Catch-up

Attachment and Biobehavioral Catch-up (ABC) is a home-visiting parenting program of ten weekly one-hour sessions, with versions for parents of children aged 0 to 6 months, 6 to 24 months and 24 to 48 months. A 2025 report says that ABC does not set experience or background requirements to become a parent coach. A 2023 trial of 454 parents compared ABC with a control intervention.

Circle of Security-Parenting and attachment-based family therapy

Circle of Security-Parenting (COSP) is described in a 2026 review as one of the most popular attachment-based preventive support programs for parents and children, with more than 50,000 participants from different professional disciplines trained in its formal protocol. Attachment-based family therapy (ABFT) is a family therapy for adolescents. In a 2023 trial it was delivered over 16 weeks to 12- to 18-year-olds with depression and suicidal ideation. The sources reviewed do not describe the content of individual sessions.

Coercive methods described by the APSAC Task Force

The APSAC Task Force describes coercive attachment therapies as using physical, psychological or aggressive means to provoke acute emotional discharge. Reported techniques include scheduled holding, binding, rib-cage stimulation, and holding a child down while several adults lie on the child or hold the face to force eye contact. Sessions were reported to last 3 to 5 hours. 'Rebirthing' simulated the psychological death and rebirth of the child, who was wrapped in blankets and told to fight free. The report also describes parent-delivered 'attachment parenting' that restricts social contact and controls the child's food and water.

The report adds that proponents describe their holding as gentle and nurturing and dispute that it involves coercion, and that they attribute child deaths to misapplication of the methods.

Uses of attachment-based programs

The reviewed trials and reviews study attachment-based programs for parental sensitivity, child attachment security and child behavior, in at-risk families, in foster and adoptive families, and with parents who have depression. ABFT has been studied for adolescent depression and suicidal ideation. These sources concern parents, caregivers and young people, and the sources reviewed do not cover attachment-informed psychotherapy for adults in couple or individual work, so nothing here applies to that use.

Claims made for coercive methods

According to the APSAC report, proponents of the coercive therapies assert that their approach alone is effective for children with attachment disorders and that traditional therapies are ineffective or harmful. They also hold that unattached children may become dangerous adults without treatment. The Task Force found no scientific support for the prediction that children with attachment problems grow up to be violent offenders, and said it was unable to locate any methodologically adequate clinical trial supporting the effectiveness claims.

Cochrane review of video feedback

The 2019 Cochrane review included 22 randomized and quasi-randomized trials with 1,889 parent-child dyads. A meta-analysis of 20 studies found improved parental sensitivity (standardized mean difference 0.34, 95% confidence interval 0.20 to 0.49, moderate-certainty evidence). For attachment security, two studies using the Strange Situation Procedure favored video feedback (odds ratio 3.04, 1.39 to 6.67), while two using the Attachment Q-Set found no effect (0.02, -0.33 to 0.38). The review rated both as very low-certainty evidence and rated all studies at high risk of performance bias, since participants could not be blinded.

Other systematic reviews of attachment-based parenting interventions

The 2015 UK assessment found, in a meta-analysis of eight studies in at-risk populations, less disorganized attachment after intervention than in controls (odds ratio 0.47, 0.34 to 0.65), mostly from interventions improving maternal sensitivity with or without video feedback. It identified one trial involving children with reactive attachment disorder.

A 2022 Campbell review of foster and adoptive families analyzed 24 of 44 eligible studies. It reported improvements in observed positive parenting, parenting stress and caregiver-reported child adjustment, but the effect on observed attachment security (three studies) was not statistically significant, and no included study measured placement stability. A 2022 meta-analysis of 25 trials of VIPP-SD reported combined effects on parenting and on attachment security but not on externalizing behavior.

Circle of Security-Parenting, Attachment and Biobehavioral Catch-up and family therapy

A preregistered 2026 meta-analysis of all eight randomized trials of COSP (1,094 families) found a nonsignificant overall effect (Cohen's d = 0.142, 95% confidence interval -0.068 to 0.353), and 82% of trials had some concerns about risk of bias. The authors concluded that evidence for COSP lags behind its uptake.

In a 2023 trial analysis of 454 parents, those randomized to ABC showed higher sensitivity and positive regard and lower intrusiveness shortly afterward, and the effect on intrusiveness persisted two years later. In the 2023 ABFT trial of 129 adolescents, depressive symptoms fell more in ABFT than in the comparison therapy for sexual-minority adolescents, but not for heterosexual adolescents, and changes in suicidal ideation did not differ between conditions. The authors call this an exploratory analysis.

Coercive methods

The 2006 APSAC report found no adequate controlled trials of coercive methods. The most-cited study, which it believed might be the only empirical study in a mainstream peer-reviewed journal, had 12 children in the treatment group and 11 in the comparison group, self-selected participants and no direct test of group differences in change. The report also says that experiments on venting anger have found it increased, not reduced, anger and aggression. These are findings as of 2006; the sources reviewed here did not identify later trials, and a narrow PubMed search for such studies returned none.

Harms reported for coercive methods

The APSAC report says the coercive techniques have been implicated in several child deaths and other harmful effects. It states that the exact number of related deaths is uncertain, that six or more have been alleged by critics, and that some deaths involved parents following therapist instructions about holding or about control of food and water. It also describes physical injury risks from force to children and adults, and critics' argument that techniques demonstrating dominance can duplicate the dynamics of abuse.

AACAP's policy statement says physically coercive methods, including forcibly holding a child, using hunger or thirst, or forcing food or water, can be dangerous and even deadly, and names rebirthing and compression holding therapy.

Professional positions

The APSAC report, endorsed by two divisions of the American Psychological Association but not by that association as a whole, calls treatments involving physical coercion, restraint, provoked catharsis, age regression, humiliation, withholding or forcing food or water, or prolonged isolation contraindicated because of risk of harm and absence of demonstrated benefit. It also says that deliberately provoking intense distress, or dismissing a child's protests, should not be done. AACAP opposes coercive interventions and supports comprehensive psychiatric evaluation and individualized plans, with family settings that give caregivers support.

Limits and harms data for attachment-based programs

For video feedback, the Cochrane review used parental stress and anxiety as adverse-event measures and found no difference from comparators (low and very low-certainty evidence); its abstract reports no other harms data. The Campbell review found the effect on child attachment security inconclusive because of few studies. These programs have not been compared with coercive methods, and a finding for one program should not be carried to others.

Assessment, suitability and care boundaries

The APSAC report advises that attachment problems be diagnosed only by a trained, licensed mental health professional with expertise in differential diagnosis. It warns that checklists posted online are nonspecific enough that false-positive diagnoses are virtually certain, that a history of maltreatment does not itself indicate a disorder, and that more common conditions should be considered first. AACAP's 2016 parameter requires direct observation of the child with caregivers. The sources reviewed identify no training standard, professional register or protected title for 'attachment therapy' as a whole. A child with persistent difficulties should be assessed by a qualified professional, and no program described here should delay or replace that assessment.