Attachment Theory Foundations

Bowlby and Ainsworth Theory

Attachment theory is fundamental to an understanding of clinical engagement, such as music therapy, with adolescents with attachment challenges. Developed by John Bowlby and Mary Ainsworth, attachment theory articulates the psychological foundations for relationship formation (Ainsworth & Bowlby, 1991). Their theory, influenced by Freud and other prominent psychologists of the time, emphasizes the importance of infant-mother attachment and the role such relationships play upon an individuals’ development. Bowlby provided many of the key ideas and definitions that formulate our current understanding of attachment, whereas Ainsworth provided the methodology to study and support the theories (Bretherton, 1992). Bowlby and Ainsworth’s theory of attachment remains one of the most influential and referenced psychological theories in practice.

Dominant western values related to socialization and upbringing elevates the significance of the parent-child relationship during infancy, specifically identifying it as the most important attachment relationship during child development. Bowlby suggests that these parental attachment relationships are imperative for “ego and super-ego development” (Bowlby, 1951, p. 53). Therefore, attachment is a “biological imperative” (Sroufe, 2021, p. 18) and a “domain” within relationships “concerned with seeking and provision of comfort and feelings of safety” (Fearon & Schuengel, 2021, p. 25). It is not the only relationship domain, and not all significant relationships are attachments. Attachment is usually characterized by a “strong desire to share feelings [with the attachment figure], greater emotional reactions when encountering them, more distress or concern upon being separated from them, and more intense grief upon their loss” (Sroufe, 2021, p. 18). According to Fearon & Schuengel (2021), we know very little about how relationships acquire an attachment domain. However, in Bowlby and Ainsworth’s theory of attachment, “attachment relationships promote security,” or intimacy, over familiarity (Sroufe, 2021, p. 21), and the child often derives an understanding of security (or lack thereof) from parental relationships. The nature of one’s parental or primary attachment relationships over time affects the formation and quality of additional attachment figures, in addition to the consistency and reliability of those additional figures.

Early attachment theory research suggested that the primary attachment figure in the infantparent relationship was limited to mothers. However, since attachment theory’s beginnings, attachment relationships have “been extended to children’s relationships with fathers and child care providers, relationships between adult romantic partners, and even relationships with siblings, close friends, teachers, and coaches” (Thompson et al., 2021, p. 4). Nonetheless, especially in infancy for Western societies, primary attachment roles and responsibilities are typically placed upon members of the nuclear family. When the primary attachment figure(s) is not present in a time of need, this can lead to changes in the infant’s mental representation of themself and others (Thompson et al., 2021, p. 4). Thus, according to Bowlby, “family experiences” are the basic “cause for emotional disturbance”(Bretherton, 1992, p. 3). This research, however, is not presented to blame emotional disturbances or attachment challenges on the attachment figures or the upbringing of a child or adolescent. Instead, it is meant to provide knowledge and support for a growing generation of individuals with extraordinary responsibilities, unique pressures, and who face systemic barriers to healthy and productive engagement as a primary attachment figure. As Bowlby suggests, “if a community values its children it must cherish their parents” (Bowlby, 1951, p. 84).

Internal Working Models

One of John Bowlby’s greatest contributions to attachment theory is his discovery and description of internal working models (IWMs) (Bowlby, 1969). IWMs are adaptive and “active constructions” of mental representations regarding the self, others, and the world, meant to further protect individuals from subjective threat or harm (Cassidy, 2021, p. 104). More specifically related to attachment relationships, IWMs “anticipate the attachment figure’s likely behavior across contexts” to allow the child to discern its level of security and still maintain energy for other tasks (Cassidy, 2021, p. 104). According to researchers Ross Thompson, Jeffry Simpson, and Lisa Berlin, these “internalized mental representations of relationships” can affect the “behaviors, thoughts, and emotions” within an attachment relationship (2021, p. 4). Filtered through their IWMs, individuals constantly assess others for potential threats to their “social connections, resource and goal attainment, and self-regulation” (Cassidy, 2021, p. 104). IWMs have “predictive, interpretive, and selfregulatory functions owing, in part, to their influences on attention and memory,” and directly impact not only present attachment relationships, but future attachment formation (Thompson, 2021, p. 129).

Besides contributing to a constant assessment of others and the world, IWMs impact identity, esteem, and an individual’s sense of self. As IWMs develop, beginning in the first year of life, early attachment experiences are pertinent to an individual’s persistent model of self (Cassidy, 2021, p. 104). As their ego and super-ego [sic] is not fully developed, an infant’s understanding of self is also often confined to a mirror of their attachment figure; meaning, their model of self is “closely intertwined with the IWMs of attachment figures” (Cassidy, 2021, p. 105). Similarly, two primary needs during infancy lead to a positive model of self: comfort and protection, and the ability for independent exploration. If an attachment figure provides both of these needs, the child is “likely to develop an internal working model of self as valued and reliable” (Bretherton, 1992, p. 23). If these needs are not met, infants, children, and adolescents alike often increase “bids for attention” by showing extreme dependence on the parent or attachment figure, often sacrificing their understanding and expression of self (Cassidy, 2021, p. 108). Ultimately, challenges in forming and maintaining attachments often originate within a negative IWM of self, others, or the world. Through therapeutic interventions involving the help of a therapist or an object serving as a reliable base for secure attachment, IWMs may transform and improve (Bretherton, 1992, p. 26).

Secure Base

To be attached is to explore with the protection of a secure base, according to Mary Ainsworth (1967). She coined the term “secure base” in her research with Ugandan infants and it was further developed in her study with the Strange Situation. With her foundations in security theory, one of the major principles that transferred to attachment theory is that “infants and young children need to develop a secure dependence on parents before launching out into unfamiliar situations” (Bretherton, 1992, p. 4). The secure base acts, not as a limitation for the child, but instead a central point or haven to return to intermittently while exploring or playing (Ainsworth, 1967). These specific attachment figures are expected to provide “protection, comfort, and relief” while “encouraging autonomous pursuit of non-attachment goals” and still remain readily available (Shaver & Mikulincer, 2021, p. 40). The attachment figures’ presence and support act as the “building blocks” for more complex IWMs to develop (Cassidy, 2021, p. 105).

Secure bases are often illustrated through examples of infant and toddler play. In a secure attachment, the child will often separate from the secure base to explore and play, but return periodically for reassurance. The accessibility of the attachment figure shapes the IWM. Besides

“sensitivity” and “promptness” of adult responses, the environment in which the attachment relationship forms plays a large role in sense of security (Ahnert, 2021, pp. 33). Shaver & Mikulincer propose that children may even have “context-specific” attachment figures (2021, p. 40), that, even for more insecure individuals, can act as “islands of security” in various contexts throughout socialization (2016, as cited in 2021, p. 42).

Furthermore, secure bases are not limited to guardians or care-providers. As an individual matures, a greater variety of “relationship partners” may become attachment figures and secure bases (Shaver & Mikulincer, 2021, p. 40). In adolescence and adulthood, even the recollection or thought of a real or imagined secure base offers the individual comfort and resources for approaching stressful situations. This sense of security is described as a phenomenon that is “partly ‘felt’ (emotionally), partly assumed and expected (cognitively), and partly unconscious” (Shaver & Mikulincer, 2021, p. 42). This security and maturity ultimately allows IWMs to also develop into a more stable mental representation and include the observed behaviors of others that was not possible in childhood (Ahnert, 2021). Therefore, security in childhood is optimal for development into adolescence and adulthood, where individuals have more choice and autonomy in their attachments. Challenges in attachment are often ignited from insecurity in a child's formative years, leading to a negative model of self or others. However, with appropriate intervention, adolescents can reform these IWMs to promote positive secure base formation and attachment security in future relationships.

Attachment Orientations

Attachment styles and orientations can reflect an individual’s model of self and others determined by their IWMs within attachment contexts. The Strange Situation Procedure (SSP) originally identified three primary classifications of attachment: insecure-avoidant, insecure-ambivalent, and secure (Jacobvitz & Hazen, 2021, p. 48). Since this experiment, fearful or disorganized attachment has been recognized as a fourth classification, and the original titles of each style have been refined and adjusted for adults and maturing individuals. Jacobvitz & Hazen explain that “the three types of insecure attachment classifications- dismissing, preoccupied, and unresolved- are based on the avoidant, ambivalent, and disorganized classifications of infant-caregiver attachment” (2021, p. 48). Moreover, the dismissing and preoccupied classifications have become synonymous with avoidant and anxious attachment orientations. Throughout this research, the terms secure, anxious, avoidant, and fearful will be utilized to name and differentiate attachment styles.

Attachment orientations are characterized by external behaviors representing internal models of self and others. Thus, they are useful for therapeutic assessment and understanding the diverse and evolving spectrum of an individual’s behaviors within relationships that contributes to their general attachment style. Attachment style is a defined and evidence-based classification that is not merely based upon temperament; it is a “lifelong process influencing humans’ capacities to form and maintain our closest relationships” (Jacobvitz & Hazen, 2021, p. 46). Past relationships ultimately affect our attachment orientation, or behaviors, in future relationships, and future relationships can continue to impact our attachment trajectories and understanding of both past and future relationships. An individual’s attachment orientation is an actively evolving cognitive, social, and emotional process (Jacobvitz & Hazen, 2021).

Individuals with secure attachment styles often expect that the “awareness of, reflection on, and expression of feelings, desires, and thoughts will result in positive outcomes” (Shaver & Mikulincer, 2021, p. 43). Furthermore, Shaver and Mikulincer, key contributors to the study of attachment, thoroughly define secure and insecure styles of attachment in relation to IWMs:

"People with a secure attachment orientation or style habitually hold positive beliefs about self and others across different relational contexts, whereas people with a less secure style hold these positive beliefs only in contexts in which actual or imagined interactions with a responsive relationship partner arouses feelings of being loved and cared for."

(Shaver & Mikulincer, 2021, p. 43).

Ultimately, secure attachments in a western context are considered optimal. A sense of security can allow individuals to focus their mental resources on “pro-social and growth-oriented activities” instead of preparing “preventive, defensive maneuvers” (Shaver & Mikulincer, 2021, p. 44). Secure attachment enables confidence in a significant context of a person’s life, which allows them to focus on growing within the other contexts (Sroufe, 2021). For insecurely attached individuals, therapeutic interventions often promote the concept of “earned security,” which describes the process of reworking IWMs to achieve a secure state of mind within attachment relationships, despite previously insecure or fearful experiences with attachment (Jacobvitz & Hazen, 2021, p. 50).

This literature review centers the dimensional perspective of attachment, a modern and salutogenic approach to understanding attachment orientations, primarily described by Raby, Fraley, and Roisman (2021). The dimensional perspective employs continuua, rather than distinct categories, which allows for an understanding of attachment as characterized by fluidity over time and across situations. This also accounts for diversity of attachment behaviors within attachment orientations and behaviors, as researchers have begun to acknowledge that differences in attachment qualities tend to appear in a matter of “degree rather than kind” (Raby et al., 2021, p. 73). Another consideration for using this model to analyze attachment lies within the axes that this two-dimensional continuum describes (See Figure 1). Raby and colleagues describe the two axes of their model as the degrees to which external behaviors reflect internal mental representations:

The first dimension involves the degree to which individuals are comfortable engaging with versus defensively avoid attachment-related thoughts, feelings, and relationship partners, whereas the second dimension involves the degree to which individuals exhibit emotional distress versus are emotionally composed in attachment situations. (Raby et al., 2021, p. 73).

These axes, labeled “emotional distress” (or “composure”) and “relational avoidance” (or “engagement”), directly relate to the IWMs of self and others. Often, psychologists will rename these axes “model of self” for the y-axis, and “model of others” for the x-axis to specifically refer back to IWMs of attachment relationships. This correlation between IWMs and attachment orientations allows for a better assessment of the potential internal and external processes within the therapeutic relationship during intervention.

Dimensional Perspective of Attachment

Attachment Assessments

Attachment assessments are typically conducted as the first step in treatment. Since its creation in 1985, one of the primary attachment assessments utilized post-infancy is the Adult Attachment Interview (AAI) (George et al., 1985). Although originally created for adults, the content has been adapted to better fit the needs of adolescents. The AAI, according to psychologists, is designed to unveil the unconscious and reveal “defensive processes that may impair adults’ abilities to provide a secure base and safe haven” within their current and future attachment relationships (Jacobvitz & Hazen, 2021, p. 47). This assessment is designed to be objective and categorical to encourage communication about generalized attachment orientations and behaviors, similar to diagnostic assessments (Steele & Steele, 2021). Through dialogue, the assessor notes and analyzes specific signs of stress when the assessee recalls attachment experiences, and uses this information to identify attachment behaviors. However, attachment quality and behaviors are identified through

“coherent, organized language” (or lack thereof). More specifically, security is “scored” through observations of “language, organization, believability, and flexible transitioning between generalized and specific memories” (Crowell, 2021, p. 87). A new wave of music therapy research suggests that attachment assessments may also be facilitated through music therapy techniques that combine music and verbal communication.

Attachment and Adolescents

Adolescence represents a period of immense change. The following literature primarily explores development through the lens of attachment theory, however, there are many more systems that contribute to an adolescent’s development within an attachment context than their level of security in relationships (Sroufe, 2021). Duboi-Comtois and colleagues suggest that adolescents' attachment behaviors are characterized by numerous changes:

Adolescent attachment is the result of both the adolescent and parent’s capacity to redefine their attachment relationship by taking into consideration the individuation process, that is, developmental changes at the social, cognitive, and emotional levels (Dubois-Comtois et al., 2013, p. 1)

To protect adolescents’ processes of individuation and growing independence, attachment becomes a “state of mind” or “symbolic” element rather than a physical presence. Attachment still guides much of the individual’s thoughts, behaviors, and coping mechanisms, but through a reformed relationship with attachment figures and secure bases (Dubois-Comtois et al., 2013, p. 2). This process of individuation changes the fundamental question surrounding mental representations within attachment from: how accessible is my attachment figure, to: “Can I get help when I need it in a way that doesn’t threaten my growing need for autonomy?” (Allen, 2021, p. 165). Adolescence is a period of development marked by the independence to shape their own new and changing relationships, which in turn affects their attachment patterns (Allen, 2021). With all of these new processes and transitions, an adolescent’s attachment security and the mental representations of self, others, and the world are constantly fluctuating. According to psychologist Allen, “stability is logically the wrong thing to be looking for” when working with adolescents and teenagers (2021, p. 163).

Coupled with the tumultuous process of individuation, adolescents’ brain development is not complete until adulthood, meaning adolescents are extremely responsive to attachment-related changes that occur during this period of development. Hughes, a psychologist with expertise in attachment focused treatment, suggests that attachment ruptures can significantly and directly impact cognitive functioning during this time (2014). Although inconsistent with Freudian theory, current research suggests that environmental changes, such as school or home location, can also significantly affect an individual‘s attachment system and processes (Allen, 2021).

Attachment behaviors established in infancy also begin their transition into an individual’s awareness during adolescence as these attachment bonds serve as the “roots” for other relationships the adolescent may pursue (Allen, 2021, p. 163). Individuals often recreate their past relationships with the hope of reworking their IWMs and expectations of attachment figures, especially those with insecure attachment in infancy. When considering new relationships, Allen adds:

Proximity, similarity of interests, sexual attraction, and compatibility, among other factors, all influence our choice of companions and will routinely leave us interacting with others who have far different attachment strategies than our own, adding new and powerful inputs to the development of attachment working models (2021, p. 166).

These new attachment discoveries within a more social context inevitably alters the nature of previous attachment relationships. And, although capacities for self-regulation and soothing are increased during this time (Allen, 2021), this expansion of one’s “attachment network” allows individuals to reinterpret childhood events through the lens of new relationships (Dubois-Comtois et al., 2013). This process of self-reflection often leads to a less stable state of attachment security in adolescence than in adulthood (Fraley & Dugan, 2021).

It is important to recognize that during this evolution of attachment processes, the externalization of IWMs can also differ from previous behaviors. Dubois-Comtois and colleagues identify these externalization behaviors as “flexible integration” and three systems of “defensive exclusion” (2013, p. 3). Flexible integration largely represents securely attached adolescents whose experiences of change during adolescence are more easily acceptable and adaptable, thus enabling more mental capacities to be devoted to personal development rather than defensive systems. Deactivation, the first defensive system, is described as the individual’s lack of attention to their “affective states or personal needs” (p. 3). This is often shown by bottling-up emotions or resisting vulnerability, as such acts of expression may have been punished in previous insecure relationships. Cognitive disconnection, however, is a defense process that specifically redirects attention away from people or events related to their emotional states or reactions, such as “changing the subject” to avoid emotional disclosure (p. 3). This behavior is most often seen among adolescents with anxious attachment orientations. Lastly, segregated systems are characteristics most often associated with disorganized or fearfully attached adolescents. Specifically in circumstances where attachment experiences may have been traumatic, the experience itself and emotional components are “segregated” or repressed from conscious awareness (p. 3).

When working in therapeutic contexts with adolescents, the primary objective should be to promote the “development of skills that normally emerge within an optimal relationship with the attachment figure” (Dubois-Comtois et al., 2013, p. 4). Attachments cannot be “fixed” but IWMs can be assessed and reworked to promote future healthy attachments. In most forms of therapy, the attachment relationship between the client and therapist will act as a key agent of change throughout treatment. However, these trusting relationships may be difficult to form, and the therapist must remain vigilant and reflexive when observing behaviors, affectional bonds, and moments of separation. Additionally preserving “optimal communication” should be at the forefront of the care provider’s mind, and it is important to allow the adolescent to explore and accomplish therapeutic objectives independently (Dubois-Comtois et al., 2013, p. 3).

Psychologist David Crenshaw, who specifically works with children and adolescents and pioneered the approach of play therapy, suggests that care providers, especially in creative arts therapies, should practice what he coins “stealth therapy” — promoting their time together as an opportunity to explore and discuss experiences and emotions, without labeling as therapy. The label therapy may activate stigmas related to mental healthcare rather than encourage the adolescent to prioritize their personal development (Crenshaw & Mellenthin, 2021).

Therapeutic intervention promotes increased attachment security for adolescents, especially in conjunction with additional treatment strategies and approaches. Reflecting on one’s challenges with relationships while integrating different perspectives (often offered by the therapist) can help adolescents to explore and reinterpret experiences with greater understanding and “integration of reality” (p. 5). Therapy can ultimately enable access to an “internal world” not previously explored, as well as safely identify and explore previously hidden emotions in an individualized environment (Dubois-Comtois et al., 2013, p. 5).

Music Therapy as Treatment Functions of Music

Creative arts therapies, such as music therapy, allow individuals to externalize their internal working models, often through more holistic and somatic experiences than in verbally mediated therapies. With numerous approaches for engagement and interaction, music often functions as a “symbol,” creating meaning from life experiences (Pasiali, 2013, p. 210). Additionally, music establishes and organizes a junction where emotional and corporal reactions are present and recognized, but not overwhelming to the psyche (Fruchard & Lecourt, 2003). Nirensztein suggests that the characteristics inherent to music allow the possibility to creatively revisit attachment experiences and conditions:

The nonverbal character of music, the complexity of its components (united in their primordial character), its unavoidable physical counterpart, its capacity to address itself simultaneously to various senses, makes it an ideal medium for re-creating conditions comparable to the constitutive experience of the self (2003, p. 228).

Through musical representation of attachment bonds, music therapy affords the opportunity for adolescents to understand and rework their IWMs. With teenagers especially, music has been culturally adopted as a mechanism of expression both within groups and individually (Fruchard & Lecourt, 2003), acting as a performance or mirror of their own identity (Ruud, 1997; Scheiby, 1991). Active or receptive engagement with music can help adolescents distinguish themselves from attachment figures, while also determining to which communities they may belong. According to Krüger (2020), at a societal level, music embodies a space for protest and change, which symbolically aligns with the therapeutic goal of refiguring IWMs while addressing adolescents’ need for autonomy amidst the process of individuation.

Music-based interventions offer different “pathways” (Pasiali, 2013, p. 203) for fostering secure attachment relationships through idiosyncratic responses in music engagement, based on internal, external, and musical factors (Hodges, 2009; Juslin, 2008). According to Juslin (2008), psychological mechanisms are involved in emotional responses to music. These include: reactions to acoustic properties, internalizing emotions perceived in music, the reminiscence or the association of memories with particular music, the validation (or lack thereof) of musical expectations, and the presence of sensations while engaging with music. With these complex and unique responses inherent to music, music therapy can provide a “container of intense emotions” that often illuminates unaddressed attachment challenges, contributing to an optimal therapeutic space for reflection and growth (Pasiali, 2013, p. 211).

Musical co-creation with a therapist or group can further encourage the process of reworking IWMs through external support or “togetherness” (Pasiali, 2013, p. 206) during the arduous process of understanding one’s own responses to music within the framework of connection and relationships (Pasiali, 2013). In this way, musical communication may encourage the beginning of new social relationships (Schönfield, 2003) and allow for closeness and more emotionally intimate connections than strictly verbal communication (Nirensztein, 2003). In musical experiences with an adolescent, the therapist or group enters their psychological space through a process of symbolization, which ultimately leads to the creation of an interpersonal or intermusical space (Pellitteri, 2008). This method of co-creation and the formation of new interpersonal spaces encourages the client to better understand their life situations, shifting from a strictly individual and survivalist approach to taking the perspective of others and the individual’s connections with them into consideration (Pasiali, 2013). Music is integral to young people’s constructions of reality by themselves and with others (Krüger, 2020). Especially for adolescents who have lived in stressful environments, learning to transform feelings into active or receptive musical engagement is an incredibly healthy form of expression (Uhlig, 2011). Music experiences, coupled with positive and co-created environments, afford a process of learning, expressing, regulating, and healing that can extend beyond the treatment process, promoting security and wholeness amidst the adolescent’s integration into society.

Role of the Therapist

Music therapists are primarily responsible for establishing and managing the supportive cocreated environment necessary for client growth in treatment. However, this task often requires the therapist to inherit many diverse roles and responsibilities. In the context of music therapy treatment, therapists can assume the role of a participant, facilitator, supervisor, advocate, educator, and stakeholder for the client at any point in the treatment process (Krüger, 2020). With adolescents, it is important for therapists to promote a consistent, collaborative space where the client has a choice in their treatment and future, as they often are placed in various settings or situations with little choice in their life circumstances. Thus, in conversations with the treatment team, family members, or other agencies, it is important for the therapist to advocate for the client as a “vehicle” for the adolescent’s voice to be heard in larger discussions pertaining to their future (Rogers, 2003, p. 132). Through detailed observations, listening, and reflexivity, the music therapist can create a therapeutic space that “allows the energy of negative emotions to manifest and change,” promoting a space conducive for positive relationship formation (Pasiali, 2014, p. 207).

In client-therapist relationships, the client’s behaviors and interactions with the therapist can often serve as a model for their own social relationships at large (Schönfield, 2003, p. 208). Thus, it is important for the therapist to reflect on how their own identities and responses, salient to the experiences in treatment, can be perceived by the client, especially when addressing attachment challenges. Identities of the therapist, such as gender, can play a large role in the therapist-client relationship, especially if the client has experienced trauma with an attachment figure of the same gender. Gender, and other identities such as race, socioeconomic class, and age can impact the power dynamics within the therapist-client relationship. It is necessary for adolescents with attachment challenges to experience relationships in which they do not feel inferior or “powerless,” so they can begin reflecting upon and reforming their internal understanding of themselves in relation to the world and others around them (Rogers, 2003, p. 136).

Similarly, it is vital for the therapist to reflect upon their own countertransference and responses when interacting with a client through effective supervision and reflexivity (Winnicott, 1965). Therapists themselves may experience moments of powerlessness and frustration, as many clients with attachment challenges have experienced some injustice or trauma with attachment figures. Therapists may even contribute to court cases in situations where the client has become victim to trauma or committed an offense themselves (Rogers, 2003). Often, when working alongside clients in such situations, the therapist is asked to help the client cope with heavy events and topics, without resolution or closure. When working with adolescents amidst these concurrent challenges, the therapist may need to deviate from their typical therapeutic techniques, as music, or a particular music experience, may not always be the most beneficial creative outlet (Schönfield, 2003). Sometimes, when dictated by the client, teenagers may just need adults who “will hear what they are trying to say,” so the therapist must trust the teenager and their goals in the therapeutic process, even if that minimizes the relevance of music (Lefebvre. 1991, p. 229). Connections between emotionally charged or symbolic (music related) expression and a client’s reality should only be addressed if or when the client chooses. Such relevant, but “difficult topics” and problem-oriented approaches should not be the immediate focus of the therapist in order to grant the teenager autonomy in determining when they have acquired the resources necessary to approach such topics (Erkkilä, 2011, p. 199). Thus, according to Rogers, by offering “careful, empathic listening, a nonjudgemental attitude, respect, a sense of safety of time and space, and a collaborative approach,” the therapist can provide an empowering space for the client which can act as a “secure base from which the client can begin to explore” their attachment experiences and other therapeutic objectives (Rogers, 2003, p. 127).

Lastly, when working with adolescents with attachment challenges, it is important for the therapist to consider and implement different treatment strategies when necessary. Krüger (2020) suggests that adolescents’ treatment and development should be perceived from both an individual and community level through the implementation of person-oriented, group-oriented, and citizenparticipation strategies which include phased interactions that foster connections, beginning with the therapist-client relationship, moving into contact with the community, towards engaging with various networks and institutions. This can account for a more holistic approach to treatment that takes culture, faith, identity, and community into consideration, which can assist the client in their integration into society as an emerging adult after treatment termination (Henderson, 1991).

Clinical Applications

Although adolescents with attachment challenges can be identified as a specific clinical group, therapeutic interactions with such adolescents often emerge in clinical settings where more specific diagnoses or reasons for referral are relevant. Working through attachment challenges can potentially be a primary treatment objective with any client or group, particularly teenagers transitioning into adulthood, and therefore may be especially relevant with adolescents engaged with music therapy through in psychiatric treatment settings, foster care programs, private practices, housing shelters, schools, hospitals, forensic settings, residential care facilities, and various child welfare programs (Eyre, 2013; Krüger, 2020).

Because music is a phenomenon situated in biological, cultural, historical, and global contexts, music therapy in these settings can give the right to play and actively participate in cultural activities back to adolescents who may have previously had these rights stripped from them. Music therapy can therefore help bridge the gap between human rights (as established by the United Nations Convention on the Rights of the Child) and a child’s reality (Krüger, 2020). In these settings, despite a country’s stance on the UN Convention on the Rights of the Child (UNCRC), it is important for the therapist to maintain a human rights-based practice to effectively advocate for the clients as human beings, capable of making large decisions, while simultaneously using music therapy as a method for protecting the adolescents’ right to a childhood.

Music Therapy Treatment Methods

Music therapy treatment involves music experiences to inspire health-oriented change. The methods of music therapy, receptive, re-creative, improvisation, and composition, categorize more specific ways of engaging with music for assessment, treatment, and evaluation. The receptive method involves listening and responding to music, re-creation involves the act of reproducing precomposed music, improvisation involves spontaneous music making, and composition involves the various ways a client may create an original musical product (Bruscia, 2014). In music therapy, multiple methods and method-variations can be combined throughout treatment to address the needs of the client. For adolescents with attachment challenges in particular, each method may afford different opportunities for understanding and reworking IWMs throughout the treatment process.

Receptive

In using receptive music therapy method variations, the client is able to use the music as a transitional object for mirroring and validating their own emotions and experiences. Often in receptive experiences, the music is central to the treatment process, symbolically acting as a baby’s blanket for support, while the therapist guides the client through verbal or somatic exploration into their mental representations of themselves, others, and the world (Dvorkin, 1991). In current treatment contexts, song listening, song discussion, song communication, and movement-to-music experiences are especially helpful in the assessment process for both the client and therapist to take a deeper look into the adolescent’s cultures, identities, and IWMs through verbal or symbolic responses to the music (Henderson, 1991; Dvorkin, 1991; Nirensztein, 2003).

Receptive music therapy experiences also assist in the early formation of a therapist-client relationship, especially for clients with attachment challenges. According to Fruchard and Lecourt (2003), “the fact that the piece of music proposed is exterior to both the therapist and the client, and is offered as a support that mediates the relationship” helps the client demonstrate vulnerability in forming a therapeutic relationship, while still maintaining boundaries and a feeling of safety and control in the space (p. 242). This can set a positive tone for the client to further invest in positive relationship formation and the music therapy treatment process.

Other music listening experiences, such as music relaxation can be useful for grounding at the conclusion of a session or for anxiety management (Lefebvre, 1991). Relaxation or Guided Imagery and Music (GIM) experiences have relatively limited applications for this client group, proving most effective for older or more mature adolescents and young adults, as music relaxation and GIM affords a more introspective and reflective approach to treatment, which can be too abstract for younger clients (Scheiby, 1991; Lefebvre, 1991). However, the "Klangbad", or sound bath, is similar to music relaxation and has been effectively implemented into music therapy sessions for younger clients. The “Klangbad,” generally includes pitched percussion instruments that emit overtones when played to provide a somatic and aesthetically pleasing listening experience (Schönfield, 2003, p. 214). This variation is often used sparingly, typically at the end of sessions to provide a brief grounding experience for the client. This experience can afford similar benefits to a traditional music relaxation experience, but can be adapted to only last a few seconds, accounting for the shorter attention span and challenge with introspective or abstract thinking.

When facilitating receptive music therapy experiences, the therapist must carefully consider the properties of any music they bring to the session. For instance, instrumental and vocal music can elicit different emotional responses for adolescents. Adolescents tend to show more direct emotional responses toward vocal music (Fruchard & Lecourt, 2003), particularly within the hiphop and rap genres (Krüger, 2020; Uhlig, 2011). The focus on lyrics and rhythms within these genres of music can be extremely supportive to the client, psychologically holding and mirroring their behaviors or emotions, essentially acting as that metaphoric baby blanket for comfort and validation (Scheiby, 1991). However, it is important for the therapist to consider and set clear expectations for music that is brought into the therapeutic space, as much of the lyrical content of songs that resonate with teenagers can include heavy, potentially violent themes and explicit language (Uhlig, 2011). If music is not permitted by the therapist or treatment setting, it is vital that the music therapist still validates the musical choices of the client and collaborates with the teenager to find another piece of music that validates their emotions and behaviors in a similar way while upholding expectations.

Receptive experiences in music therapy are a very useful and relationship-fostering method for the assessment process and start of treatment because they offer something external and familiar for clients who may be hesitant toward creating an intimate relationship or engaging in unfamiliar musical experiences. However, as the therapist-client relationship develops, adolescent clients’ desires for treatment often evolves into a inclination to “create something” instead of continuing with passive listening and verbal processing (Erkkilä, 2011, p. 203). Often, adolescents in music therapy have already met with other various health professionals and “may be tired of talking about [their] problems” (Erkkilä, 2011, p. 199). Thus, after the initial stages of the treatment process, more active methods of musical engagement may afford new opportunities for health and development for the client.

Re-creative

In music therapy with adolescents with attachment challenges, re-creative method variations are typically limited to experiences implemented in adapted music lessons and music performances to showcase their musical growth. Teenage clients often gravitate towards product-oriented approaches to music therapy, particularly experiences that encourage a more original creation or performance. Piano and guitar lessons are often popular with this client group, and teenage clients tend to enjoy learning the instrument through re-creating familiar songs (Lefebvre, 1991). Similarly, as clients become more skilled in their vocal or instrumental technique, often recording or performing covers of familiar songs results in a product and accomplishment that the client can hold onto and share both inside and outside of the therapy session, ultimately encouraging positive change in their internal model of self. These re-creative experiences with precomposed music often lead to an interest in the client creating their own original music, either spontaneously within sessions or through a composition process.

Improvisation

Spontaneous music making can allow both the therapist and adolescent to discover, communicate, and reflect upon their IWMs and attachment experiences. Often, overwhelming emotions and thoughts can be better expressed and understood through more abstract and somatic forms of communication. Scheiby (1991) suggests that improvisation originates from a “natural impulse,” and organically engages the whole self; mind, body, and spirit, which can encourage the truest form of self to emerge (pp. 294-295). Especially in cases where the client was not encouraged to communicate freely through language in their previous relationships, improvisation can act as another method of communication in new relationships or attachments (Oldfield, 2011).

Improvisation experiences afford new possibilities for interpersonal and intrapersonal dialogues that can provide a foundation for self-transformation throughout treatment (Scheiby, 1991).

Non-referential instrumental improvisation can be an accessible and symbolic way of learning more about a client’s mental state (Schönfield, 2003). Through free improvisation, the adolescent is able to externalize feelings that they may perceive as forbidden or dangerous (Bruscia, 1987); therefore enabling venting through an emotionally-charged experience that could be seen as behavioral dysregulation or “acting-out” in other contexts by other care providers in the adolescent’s life. In improvisation experiences, it is the therapist’s responsibility to safely guide the client through the experience by providing support as needed, and cautiously interpret the client’s music.

While the therapist observes and guides the client through a free improvisation, they should specifically take note of the client’s implementation of leitmotifs, as they can play a large role in the externalization of IWMs (Nirensztein, 2003). In the assessment process, Jenny, a child victim of sexual abuse, often improvised musical “ditties” on a xylophone that resembled nursery rhymes (p. 129). Rogers (2003) interpreted these ditties or leitmotifs as a demonstration of her anxiety and an attempt to please the therapist (acting as the only adult in the room). Similarly, the repetition of these familiar ditties also demonstrated Jenny’s challenge to find her own voice, as her individuation process was stunted by the trauma she experienced (Rogers, 2003).

Non-melodic musical qualities of improvisations, such as rhythm and tempo, can also provide useful insight into the client’s IWMs. In an instrumental improvisation, Patricia, a teenage client from the Xhosa Tribe in South Africa, chose 6/8 as the desired meter for the improvisation. Henderson (1991) interpreted that musical choice and quality as an expression of Patricia’s need for comfort, as 6/8 often provides a rocking feel, resembling a caregiver rocking a baby. Ultimately, a client’s spontaneous musical choices can illustrate their current mental state, resources, and needs throughout the treatment process.

For many adolescents with attachment challenges, there is often a history of trauma in their relationships with attachment figures. Such trauma experiences can lead to the experience of overwhelming emotions amidst improvisations. In order to ground and support the client during such experiences, the therapist can provide or encourage the use of secure bases through musical elements. In Rogers’ work with Jenny, the use of a repeated musical “cell,” containing three pulsed chords, acted as a secure base that was external to the therapist and client (2003, p. 133). Similarly, with Linda, a teenager with a history of attachment challenges, the client was encouraged to improvise on piano, but through a technique of dividing the keys. Linda then was able to improvise using a singular key or range of keys to act as a secure base, the other pitches merely acting as her attempt towards musical exploration, and symbolically, exploration of her IWMs. Having a secure and predictable home base consistently available afforded Linda the opportunity to take her time exploring the instrument and creatively coming up with her own improvised melodies (Dvorkin, 1991). The musical secure base can come from the client or the therapist’s music, but it must include a consistent, reliable, and replicable musical structure that can simultaneously act as a musical space for comfort and a launchpad for further exploration. To best support the client in the arduous task of reworking IWMs, the therapist should facilitate and encourage the use of musical secure bases amidst improvisation experiences, as such predictability and security directly counters early experiences of instability and therefore provides previously unavailable resources for freer and more confident exploration and relationship formation.

Often, proposing a prompt or title for a referential improvisation experience can guide the client towards more focused creative expression, with less risk of overwhelming the client through more directed emotional exploration (Scheiby, 1991). Similarly, implementing play therapy approaches with improvisation experiences can provide a focused goal or familiar experience that can be less daunting to a new music therapy client. The act of play contributes to personality development and eventually, individuation. Thus, especially for adolescents who may have experienced delays in the individuation process due to trauma, utilizing props, toys, or puppets in the musical space to contribute to projective musical stories can help clients displace significant emotions and events, while still working through them in the musical space (Henderson, 1991).

For adolescents less receptive to play therapy techniques, song story experiences can still be facilitated through vocal improvisation, omitting the props entirely. This can occur through a musical dialogue, where the client and therapist engage in free associative verbal processing but with a melodic and metric component that supports the musical phrase (Dvorkin, 1991), or through a production-like monologue or song, which can often contain a metaphorical account of the client’s experiences with attachment figures. By verbalizing with a musical setting, clients are often able to better comprehend and reflect upon their experiences and behaviors, as the musical elements afford greater emotional expressivity and connection.

Once again, it is important for the music therapist to assess the musical components of the client’s improvised song story as well as the lyrical content they deliver. For this client group, improvised song stories can lead to the disclosure of traumatic experiences, so it is important to consider how the therapist’s support in the experience (musical or otherwise) may be linked to transference and countertransference anxieties (Rogers, 2003). Nonetheless, improvised song stories can afford transferable skills of boosted healthy expression and improved emotional awareness, as the client begins to bridge connections between their internal symbolic representations and external verbal expressions.

Composition

Similar to improvisation method variations, composition experiences can provide a reflection of the client’s psyche. Composition can enable symbolic and verbal expression processes and allow the teenager to create a tangible product. While improvisation primarily supports externalization of IWMs, composition can help to reflect and rework them. Composition can occur through recording original music, writing music, creating a method of notation, or transforming a pre-composed song by composing original lyrics. This process ultimately unlocks the adolescent’s emotional world, but more importantly, affords the opportunity for learning and adaptation (Uhlig, 2011). In composition experiences, the client is granted the autonomy to change their lyrics, harmonies, melodies, or any musical component at any time. For clients that often do not have much of a voice in controlling their life circumstances or making choices to impact their future, this experience can be extremely empowering.

The songs a client creates can act as transitional objects to absorb and reflect their thoughts, emotions, and behaviors. From the therapist’s perspective, Dvorkin explains:

"While the therapist is the transitional object in verbal therapy based on object relations theory, the use of the song in this manner freed my role in the therapy process and the way in which I could relate to Linda during the various stages of therapy." (1991, p. 259).

While the active composition process affords an abundance of transitional experiences and knowledge, the completed composition itself is often valued by the client because it is something that they can continue to hold onto as a product, even after treatment termination. Through modern technology, clients can potentially listen to and view their composition at will, and even employ the skills they learned or honed in music therapy to continue composing outside of therapy as a method of expression.

Like song stories, compositions can encourage the client to symbolically and verbally reflect upon their mental representations of themselves in relation to others and the world around them. While improvisation involves a spontaneous process of musical creation, without intentional reworking or adjustments after the process unfolds, composition experiences are characterized by a process of development, decision making, and adjustments. With such aspects inherent to the composition process, composition experiences with adolescents often take multiple sessions to complete, which may not be realistic in all treatment settings with this client group. In individual music therapy sessions with an adolescent with attachment challenges, composition experiences were primarily utilized with clients who participated in treatment for months or years (Dvorkin, 1991; Scheiby, 1991; Uhlig, 2011). The composition itself served as a product representing their growth and development through treatment, which often contributed to positive change in their model of self. Therefore, in treatment environments where the length of treatment is more limited, it may be beneficial to introduce tools and resources for the client to engage in their own composition processes after treatment termination. Similarly, combining different method-variations to turn improvisations into product-oriented experiences or compositions can help support the client’s growth despite time limitations. As previously mentioned, therapists working with this particular client group will often be tasked to creatively think beyond their typical music therapy procedures to best support the adolescent and their goals.

Criticisms

Although psychological research and healthcare applications pertaining to adolescents with attachment challenges are rapidly growing, clear guidance for music therapy practices with this particular client group is still lacking as a result of limitations in the applicability of attachment theory to diverse clients, lack of regard for barriers to treatment access, and often in limited music therapy approaches to treatment.

Attachment Theory Criticisms

Attachment theory origination dates back to the 1950’s, and like many psychological foundations, is rooted in white supremacist values and biases surrounding health. Beginning with the pathogenic perspective on attachment classifications, Bowlby and Ainsworth’s theory proposes a level of universality of their four classifications, secure attachment being the most optimal or “healthy.” However, current research debates the functions of universal versus culture-specific approaches towards attachment (Bretherton, 1992, p. 30). Using similar attachment assessments, psychologists found different attachment styles to be dominant in different cultures and locations. For instance, avoidant attachment was over represented in north Germany (Grossmann, Grossmann, Spangler, Seuss, & Unzner, 1985), while anxious attachment appeared more frequently in Japan (Miyake, Chen, & Campus, 1985) and Israeli kibbutzim (Sagi et al., 1985). Knowledge of socialization strategies in cultures other than the Western middle-class are largely unexplored in academic literature, but much of the difference in attachment classification dominance pertains to cultural emphasis on collectivist versus individualistic values (Keller, 2021). With Bowlby’s theory focusing on the effects of familial relationships, the cultural variations on the definition of a ‘family’ can play a large role in attachment styles. Thus, identifying attachment classifications rooted in individualistic values as more healthy or optimal can perpetuate white supremacy.

Furthermore, popular attachment assessments, such as the AAI, are limited by their strictly English language and narrative-based evaluations of the client that generalize mental representations of attachment, typically through the discussion of one particular relationship. Although there is value in utilizing narrative to assess IWMs and attachment orientations, this categorical and verbal assessment can also provide inconclusive and biased results for various clinical groups including, but not limited to: neurodiverse individuals, non-speaking individuals, client groups with various dialects or levels of education that differ from the psychologist assessing, and clients who may not speak English as their primary language. However, I believe the use of music as a communicative device and object for attachment can supplement these limitations to support a more holistic and equitable approach to mental health assessment and treatment, especially when working with adolescents in this context.

Lastly, many of the foundational assumptions in attachment theory are ambiguous and don’t account for the diversity of adolescent and adult relationships and the factors that may affect attachment orientation (Keller, 2021; Aviles & Zeifman, 2021). Most attachment theory research focuses on maternal and marital relationships. Yet, attachment figures can include other close relationship partners such as siblings, friends, teachers, or any relationship figure that acts as a stable point of reassurance, protection, and advocacy for the individual (Aviles & Zeifman, 2021). Attachment research would often criticize independent adults, identifying their relationship choices as “personal deficiencies” (Aviles & Zeifman, 2021, p. 56). Similarly, reigning attachment assessments assume adult (and adolescent) attachment patterns directly parallel individual differences established in infancy, without taking temperaments and personality into account (Crowell, 2021). There are numerous factors across the lifespan that may contribute to an individual’s attachment orientation. Specifically, systemic oppression and marginalization lead to less secure attachment experiences for victimized groups (Bretherton, 1992). Furthermore, there is a significant lack of information on adolescent attachment patterns and orientations as compared to other age groups (Ruby et al., 2021). Ultimately, there are significant and relevant components of attachment, which are largely unknown to psychologists, thus making attachment challenges difficult to define and treat in therapeutic contexts.

Sociopolitical Limitations

Just as the field of psychology is rooted in white supremacist values, mental healthcare is also rooted in oppressive systems that continue to harm marginalized communities. Access to outpatient and individual treatment, especially music therapy, is extremely limited for many client groups. Adolescents with attachment challenges are an extremely large clinical population, yet they are often underserved due to systemic limitations and stigmas concerning mental healthcare. This contributes to a lack of research for this clinical group.

Adolescent access to healthcare and treatment is also influenced by legislative and societal systems of provision and protection. For many countries, this includes the UNCRC, which advocates and protects the rights of children and adolescents. It focuses on a sustainability and human-rights based approach towards welfare and safety, taking culture, community, and values into account. The UNCRC protects children’s right to engage culturally with the community, play as a formative activity in childhood, and participate in active citizenship, all rights that could be upheld and supported by music therapy practices. Furthermore, the UNCRC protects child access to healthcare and educational resources (Krüger, 2020). Through protective and provisional systems such as the UNCRC, children and adolescents are considered rights holders and rights bearers, which leads to more supervision and delegation of the process of upbringing to ensure such rights are honored. Although most countries have adopted and ratified the UNCRC, much psychological and healthcare innovation derives from the United States of America, which is one of two remaining UN countries to not ratify the UNCRC. Skeptics in the U.S. suggest that the convention undermines parental authority, and current systems and limitations of child welfare and healthcare resources often reflect the prioritization of adult rights and citizenship (Krüger, 2020).

Although the rejection of the UNCRC in the United States challenges adequate provision of support for adolescent clients with attachment relationships, music therapists and organizations may still reflect the values of the UNCRC in their practice through attempts to provide more treatment accessibility to adolescents, clearly communicate the rights and options a client may carry, and promote active citizenship and cultural engagement through music therapy. The values framework of the UNCRC is extremely relevant to music therapy with adolescents with attachment challenges, but has often been neglected in research, theory, and practice. Thus, it is therapists’ responsibility to implement this human-rights based perspective on child welfare into their own practices as healthcare professionals (Krüger, 2020).

Music Therapy Practice

Although music therapy as a discipline aims to be innovative, progressive, and an equity-based practice, treatment and research is quite limited and often unrealistic or inaccessible to communities that may benefit from culturally-responsive music therapy services. Most case studies and research surrounding adolescents with attachment challenges favor individual music therapy sessions with private institutions or practices that exclude clients of a lower socioeconomic status. In reality, many adolescent clients with attachment challenges are referred for music therapy in welfare programs or public institutions that likely do not have a large enough budget for individual music therapy sessions to be offered to every client (Krüger, 2020). Group music therapy sessions are more practical and accessible for adolescents with attachment challenges, yet there is limited research on treatment best practices and considerations for addressing attachment-related concerns and challenges in a group setting with teenagers. Potential integration of Community Music Therapy (CMT) practices, which would provide a more accessible, equitable, and culturally driven approaches to treatment that largely defy capitalist systems in healthcare, could help to minimize gaps in theory and practice. Nonetheless, adolescents with attachment challenges make up a large clinical population that many music therapists will encounter in their careers, so it is important to consider the demographics of clients and reflect upon how our practices can better promote an integrated and equitable approach to healthcare that serves the whole community.

Conclusion

As extensive and detailed the current psychology and music therapy research related to treating attachment challenges among adolescents aims to be, there are still many treatment approaches and considerations that are only beginning to be explored and examined. More research in group music therapy is especially necessary to fully consider equitable treatment practices when working with adolescents with attachment challenges. Similarly, current music therapy research promotes the relevance of music as a communicative device and attachment object that can be supplemental to traditional narrative-based therapies. However, music is also a cultural tool for building relationships and community, providing an opportunity for external relationships to take place within musical engagement. Community Music Therapy could afford a more collectivist approach to fostering positive attachment relationships, and gradually integrating adolescents into more central and respected roles in society through musical engagement that encourages solidarity. An integrative perspective towards treatment that supports clients in their natural environment may produce more transferable skills related to the reworking of IWMs.

Music therapists must continue to advocate and support their teenage clients with attachment challenges through the innovative and creative intersection of diverse theories, therapeutic approaches, and evolving research. No single theory or treatment consideration will be universal to all adolescents with attachment challenges. As therapists encourage growth and holistic development within clients, it is crucial for the therapist to persistently think reflexively and strive for similar goals in their practice.

Acknowledgements

I want to sincerely thank the Berry Family and Foundation for their financial support as well as the University of Dayton Honors Program for supporting my development as an undergraduate researcher in the Berry Summer Thesis Institute 2022. Furthermore, I would like to express my utmost appreciation to Dr. Samuel Dorf and my research mentor, Professor Joy Willenbrink-Conte for guiding me through each and every step as I emerge into academic conversations within the music profession. This program gave me the incredible opportunity to not only learn more about research and my future career as a music therapist, but also the chance to interact with a wonderful group of brilliant, determined, and kind individuals through our exploration of the intersectionality between research, ethics, and service.

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