Treatment Outcome Research
On this page, we will cover the following topics.

Clinical Research Shows Corrective Attachment Therapy™ Works
Treatment Effectiveness
Adult Treatment Outcome Research   (Summary, Conclusions, Discussion)

Clinical Research Shows Corrective Attachment Therapy™ Works
By Terry Levy and Michael Orlans
A retrospective longitudinal research study was recently conducted at the Evergreen Psychotherapy Center. This study was designed to determine the effectiveness of Corrective Attachment Therapy, a combination of emotional, cognitive and family systems therapy as well as parenting-skills training.

The study contained two parts. The first part examined the demographic and clinical characteristics of 50 children and families who participated in the two week Corrective Attachment Therapy treatment program. The second part examined changes in the behavior and attitudes of children who completed therapy. Symptom reduction was determined by comparing scores on the 50-item parent reported Symptom Checklist pre- and post-therapy. Following is a summary of some of the findings.
Descriptive Analysis
Adoption Background Percent of
Studied Group
Adopted 84%
Different race/ethnicity than adoptive parents 46%
Adopted as part of sibling unit 45%

Serious disruption and damage in the children's attachment histories was found.

Placement History Percent of
Studied Group
One or more foster care placements prior to adoption (average of three placements) 72%
Experienced severe and chronic physical, sexual and/or emotional abuse prior to adoption, with a mean of 48 months 90%
Were forcefully removed against biological parents' wishes 56%
Spent considerable time in foreign orphanages 34%

These children had severe psycho-social problems: 92% had a prior diagnosis of RAD, and 76% had multiple diagnoses (for example, Oppositional Defiant Disorder, ADHD, PTSD, Depression).

Parents reported more severe symptoms in their children prior to treatment due to:
  • parents and child of a different citizenship (cultural and ethnic differences)
  • length of time abuse and neglect occurred prior to adoption
  • number of years child spent with biological parents
  • prior diagnosis of PTSD and/or several diagnoses in addition to RAD.
Parents with secure attachment histories reported lowest symptom severity (34% of mothers and 38% of fathers).

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Treatment Effectiveness
An analysis was conducted on the pre- and post-Symptom Checklist scores, measuring the child's improvement on six symptom categories (behavior, emotion, cognition, relationships, physical, and moral/ spiritual).

Statistically significant positive changes were found on all six symptom categories up to three years after therapy. Improvements held over time.

Children improved more when they had the following characteristics:
  • fewer moves in the foster care systems
  • fewer pre-therapy diagnoses
  • were not adopted as a sibling unit
  • were not taking psychotropic medications during therapy
  • had an adoptive mother with a secure attachment history
These research findings have important implications for children and families. First, the research proves that Corrective Attachment Therapy does help children with histories of maltreatment and compromised attachment. It also confirms that multiple placements in foster homes are damaging to children and make treatment more difficult.

Interestingly, although there are times when adopting sibling groups is appropriate, the findings show that certain sibling group adoptions can result in severe problems for children and parents, and inhibit the development of secure attachment (for example, when the siblings have pathological patterns of relating, such as physical and sexual abuse).

The research also illustrates that the pros and cons of medication must be weighed, as it can interfere with treatment results.

Finally, the findings show that the parents' attachment history and current level of emotional maturity play an important role in the success of treatment and the child's long-term improvement.

For more information on Corrective Attachment Therapy, see Attachment, Trauma and Healing, (T. Levy and M. Orlans, Child Welfare League of America Press, 1998).

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Adult Treatment Outcome Research
By Anthea G. Coster, Ph.D.
Attachments formed in childhood lay the foundation for the health of our adult relationships. Feeney et al. (1996) address this basic principle, which this research supports. The two-week Corrective Attachment Therapy, Intensive Outpatient Psychotherapy program at the Attachment Treatment and Training Institute of Evergreen Psychotherapy Center (ATTI/EPC) addresses the issues of attachments formed in childhood, and helps individuals to recognize their attachment styles, patterns and the effects on their intimate relationships.

Focus of literature and research on adult attachment and therapy has become more prominent in the last decade. Attachment therapy has come under attack over the past five years or so because of experimental therapies that have concentrated on control of the child during therapy, to the point of abuse and death. Corrective Attachment Therapy is the therapy that is carried out at the ATTI/EPC. This research sets out to show it is grounded in well-founded therapy methods, with a view to developing loving connection and communication within a family system. It concentrated on outcomes with the adults who have experienced the various components of Corrective Attachment Therapy (HNP; ACT; CAP). Millikin (2000) did research on a similar therapy, Emotionally Focused Therapy, with three couples; this research is the first outcome study with adults who have experienced Corrective Attachment Therapy as practiced by the treatment team at the ATTI/EPC.

The hypothesis was that "Adults who attend and complete the two-week Intensive Corrective Attachment Therapy program reduce their attachment and trauma symptomology and improve their quality of life". The purpose was to gather information about the adults that would support exploration of the hypothesis and answer the questions that arise around the hypothesis. The results appear to support the hypothesis: a majority of clients reported low stress and trauma in their lives, on the TABS measure, and an average to high quality of life, on the QOLI® measure, after treatment. As attachment is to do with the relationships in one's life, the Other Intimacy (OI) scale of the TABS and the Love scale of the QOLI® were particularly highlighted in comparison to stability of relationships at the beginning of treatment. Again, the results appear to support the hypothesis.

The Adult Attachment Inventory and Bartholomew's classifications of adult attachment were used to determine attachment styles. As with Millikin's Emotionally Focused Therapy study, attachment wounds were identified. The assumption was that these were resolved in treatment because of the intensity and focus of the treatment.

Corrective Attachment Therapy is based in family systems, trauma resolution and communication work. In his family systems work, Bowlby (1988) expressed the very characteristics of treatment that Corrective Attachment Therapy encompasses: the history of the adult's experiences as a child; their relationship / attachment to their parents; the type of parent they had; the communication experienced; and their experiences and capabilities with eye contact. Doyle et al. (2000) predicted the parent / child to adult patterns uniquely with both mother and father, based on the parents' attachment style. Hendrick et al., (1994) had looked at much the same patterns. Many other writers and researchers have looked at the exploration and gathering of information concerning attachment patterns in adult relationships. This research found that the securely attached did better in relationships than the insecurely attached before treatment, and that after treatment there was little difference overall between the groups.

Clulow (2001) looked at preventative communication skills that helped couples review their relationship patterns and assumptions, much as ACT did in this study. Patterns of communication were shown in this study and other studies to be assimilated in families of origin (Botta et al., 2000). Wallerstein et al., (1996), Gottman (1994) and Richo (2002) all included attention (listening and attunement), sharing, and reality in their keys to having an adult long-term relationship. The ACT stresses these attributes and sets up a forum where each person can feel heard and understood. ACT also eliminates the destructive patterns of criticism, stonewalling, defensiveness and contempt (Gottman, 1994), instead encouraging calmness, acceptance and validation. Once ACT is taught to the adults, they practice it over the ten-day period of the therapy and are encouraged to use it on a regular basis. Richmond et al., (1997) noted that higher degrees of communication lead to improved satisfaction in marriage.

The clients with unresolved attachment were able to resolve trauma through the Corrective Attachment Therapy components of HNP/PDR and ACT, and have found the strength to move on with their lives with hope for the future. Posttraumatic stress disorder resolution through the HNP/PDR has allowed other clients to state that they can relax, sleep properly, and enjoy their lives, these being new experiences that allow them to feel "normal" for the first time in their life. Dr. Levy and Michael Orlans' Revise, Revisit, and Revitalize, treatment model falls into the same categories of previously accepted posttraumatic stress disorder theories of Hansen (1992), Matsakis (1994, 1996) and Schiraldi (2000). Levy and Orlans combine this model with the HNP which addresses attachment issues and provides security and connection throughout the experience.

The treatment team is experienced in the field of attachment, with Dr. Terry M. Levy and Michael Orlans having written their third book on the subject of, "Healing Parents." The clients who come to the center, although they are often anxious and nervous on arrival, come to trust the team to understand the issues involved. Therapy is done with the client; they have a voice in their treatment, and they become a member of their own treatment team. This approach fits into attachment models described by Dozier (1990), Dozier et al (2001), Hazen et al., (1994), and Holmes (1996).

Conclusions

The adults who attend the Center for the two-week IOP CAT program do not have the same ratios of attachment styles as is found within the general public. This is to be expected due to the circumstances under which the adults and families come to the center. The adults are typically driven to seek out the therapy because of their inability to deal with the chaos in their lives. The families are driven overall by the severity of the symptoms of the child(ren) in their home and their personal inability to deal with these problems. Linda Pearson (2002) found similar ratios of secure and insecure attachment styles within the parents included in her study. She also found that the more secure the parent, the less severe the reported symptoms of their children. Thus, more secure parents will not seek treatment at this level, where insecure parents will look for intensive help.

The adults' attachment style has a definite effect on the stability of their intimate relationships. At the time of treatment, 85% of the secure adults were in a stable relationship. More of the insecure classifications were in unstable relationships; Dismissing 58.3%; Preoccupied 61.5%; Unresolved 80%. Post treatment, all of the adults in stable relationships indicated average and above average satisfaction with their current love relationship (QOLI® Love Scale), and only 3 (10.7%) indicated discomfort in their intimate relationships with others (TABS: OI). In the unstable relationships, 67.9% indicated average and above satisfaction with their current love relationship; 31.8% were dissatisfied; 9 (40.9%) indicated discomfort in their intimate relationships with others (TABS: OI). Overall, only 7 (14%) scored below average on the QOLI®. Of these 7, three were single mothers who were not in a relationship, thus they were dissatisfied with their relationship's non-existence. Of the other four, one has since divorced, having come to treatment to determine if divorce was the right thing for her to do. The other three were still in marriages where their children or partners were still a major cause of stress.

Those with secure attachment styles did not participate in the HNP / PDR at the same rate as those with insecure attachment styles, as they do not have the same levels of trauma from childhood that affect their lives today. All parents were exposed to the CAP, which, as they learn to put it into place, lowers the stress factors associated with dealing with their attachment disordered child(ren). All couples learned and experienced the ACT, which incorporates the patterns of attachment from their childhood.

The mean TABS scores on all measures were lower than those of the population used for validation and reliability of this measure. Across all the attachment styles, a vast majority scored in the high average and lower trauma range.

The mean QOLI® scores were also average or better than average in most cases. Those in the stable relationships were all satisfied with their intimate relationships; a majority of those in previously unstable relationships reported being satisfied with their intimate relationships after treatment.

Discussion

The study has produced results that generated a wealth of information, much of it not highlighted in this paper. The breakdown of each case's sub variables on each test will be looked at, and those who are identified with having a problem area will be contacted directly by the researcher so that they can be advised of specific strategies they can use to reduce their stress in that area. This may involve them working with a therapist in their hometown. One of the adults, who had Dissociative Identity Disorder/Multiple Personality Disorder, used the tests to talk to her hometown therapist before she mailed it back, and then sent a letter to say that through doing the tests she realized just how much the Corrective Attachment Therapy had helped her integrate her life and move forward. She scored in the above average scales in both measures.

Email and phone conferencing with the adults, their therapists, and their children's schools are common practice. Cases that come from local areas in Colorado are seen for any necessary follow-up at the Center if possible. Over time, a few clients have returned to deal with old issues that they feel they have not resolved, or to deal with new issues that have arisen as they have made changes in their lives.

The majority of clients keep in contact with the team, frequently expressing their thanks for the help that has given them the ability to change their lives for the better. This study puts those expressions into a format that can be used for others seeking treatment, so that they can be reassured that Corrective Attachment Therapy has a solid theoretical foundation and produces positive results.

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