Attachment Trauma Re-Viewed: A Commentary on Farina and Schimmenti (2025a)

Abstract

Farina and Schimmenti (2025a) have made a major contribution to furthering our understanding of early developmental trauma and its serious, long-term, psychosocial effects, while pointing toward therapeutic approaches deeply informed by their rich conceptualization of attachment trauma (AT) and clinical acumen. The authors’ impressive review and integration of a wealth of developmental and clinical research has led them to propose a sophisticated yet clear definition of AT, as well as important notions on its relationship with disorganized attachment (DA) and a helicopter view on its treatment. We identify several appreciations of the authors’ conceptualization and applications to clinical practice; offer suggestions for further clarification and expansion of ideas; and finally propose how we might “continue the conversation” with an emphasis on clinical theory and practice, past, present, and future. Farina and Schimmenti are to be strongly commended for providing a solid foundation from which to pursue, with greater clarity and intention, our field’s ever-deepening and hope-engendering understanding and treatment of survivors of AT, for patients, therapists, and concerned loved ones.

Introduction

Farina and Schimmenti (2025a) set themselves a considerable challenge: to meaningfully situate attachment trauma (AT) in the context of diagnosis and treatment. We congratulate the authors for their impressive integration of a wealth of developmental and clinical research. They identify three objectives in their review: defining AT and differentiating it from other related constructs; demonstrating how AT underlies a broad range of mental disorders, with an emphasis on psychopathogenic processes; and integrating their understanding of AT into psychotherapeutic practice.

Our commentary is comprised of three sections. Section 1 is devoted to highlighting some of our many appreciations of the authors’ significant achievements. Section 2 outlines three areas we believe would benefit from clarification and expansion. The final Section 3 extends the conversation as we look forward and consider areas for future research and psychotherapeutic practice.

Section 1: Appreciations

It is increasingly recognized that various forms of child abuse and neglect have a significant impact on the psychological and physical health of their survivors, as well as broad relational and societal repercussions. However, a persistent obstacle to deepening our clinical understanding and treatment effectiveness is the lack of clarity about which phenomena are most important to attend to and how to define them. For instance, “child abuse and neglect” are typically differentiated as if neglect is not abusive and abuse is not neglectful. The lack of agreement about characterizing this form of early trauma, its relevant factors, and their interrelations has created a veritable confusion of tongues, to borrow Ferenczi’s (1933) still-relevant expression. As a result, the authors aim to bring much-needed order and direction to this field by integrating a plethora of developmental and clinical research, while also offering crucial psychotherapeutic applications of their synthesis.

Given this historical backdrop, Farina and Schimmenti (2025a) have made a significant contribution to conceptual house-cleaning concerning early developmental trauma. They have created an essential milestone in conceptualization, integration of developmental research, and treatment perspectives.

Attachment trauma (AT) defined

The authors’ perhaps most central conceptual goal is to define AT and differentiate it from other related constructs such as Complex PTSD (C-PTSD), developmental trauma, and early relational trauma. Toward that end, they offer a richly complex and integrative definition:

Attachment trauma is a condition that emerges within primary attachment relationships, in which prolonged and severe failures in protection, regulation and caregiving, and/or the occurrence of active and ongoing abuse, represent lasting or recurrent threats from which the child is unable to escape. This includes prolonged and severe affective, attentional, cognitive, motivational and neurovegetative misattunement in relational exchanges with neglectful and/or abusive parental figures that impede or hinder the child’s normative physiological, socio-emotional, and representational development. (pp. 9-10; italics in the original).

All too often, “attachment” has been associated with “wound” or “injury” and not “trauma”. For some researchers and therapists, the terms “wound” or “injury”, particularly concerning subtle yet chronic and pervasive forms of neglect, do not garner sufficient clinical concern and, as a result, therapeutic attention. “Wound” and “injury” are often connoted as discrete events that can be more readily ameliorated. In contrast, trauma, particularly AT, is understood to be complex and chronic in etiology and effects and, in turn, requires complex, intensive, and typically longer-term treatment. We appreciate that the authors’ terminology and conceptualization capture the seriousness and significant challenge of our shared endeavor.

The benefits of the authors’ comprehensive description of AT also include the caregivers’ failures to protect, regulate, and nurture the developing child; the importance of AT as a consequence of abuse and neglect, recognizing these often co-occur (US Department of Health and Human Services, 2000); and that AT impacts a broad range of neurophysiological, cognitive, affective, and motivational systems. The authors also emphasize that AT impacts both observable behavior and mental representations (e.g., internal working models; Bowlby, 1969).

AT: Transdiagnostic psychological processes

Of particular importance and potentially “game-changing” for our field is the authors’ exploration of AT as a permeating psychopathological dimension that may underpin a broad spectrum of mental disorders first manifesting in childhood and later adulthood. The value of their adopting a transdiagnostic, dimensional approach instead of thinking in terms of discrete categories, already proposed a century ago by Pierre Janet (1921), cannot be overemphasized. They list a series of psychological processes that may characterize, to a greater or lesser extent, all mental disorders involved. Among these are dysregulation of arousal, affect, and impulse control; pathological implicit beliefs and mental representations of self, other, and relationship; impaired mentalization and epistemic trust; as well as detachment and dissociative reactions, which we would like to comment on later.

AT: Inferential identification and underreporting

The authors also recognize a central clinical dilemma with respect to AT: explaining how AT results in diverse clinical presentations, while also acknowledging that adult survivors are often unable to recall the events researchers and clinicians can only infer. Their “clinical approach involves inferring the presence of attachment trauma from a specific constellation of psychopathological manifestations, clinical indicators, and therapeutic challenges…” (p. 7), as research shows AT history, particularly in cases of neglect, is typically underreported by patients and clinicians alike (Leeds, 2024; McLaughlin et al., 2017).

AT and disorganized attachment: Overlap and differentiation

The authors (ibid) also discuss, at some length, how disorganized attachment (DA) must be differentiated from AT. They suggest that DA does not necessarily result in longer-term psychopathology, whereas AT typically does; and most importantly, that “DA is better represented as an internal configuration of severe attachment failures …, whereas attachment trauma can be better conceptualized as the potentially pathological process stemming from the consequences of these interactions” (p. 13; italics added). We will offer additional perspectives to the DA/AT discussion (Section 2).

We also want to acknowledge that the authors allude to a complex relationship between DA as “internal configuration”, inferred from painfully disoriented behavior, and “pathological processes” stemming from conflicted intrarelational and interrelational interactions. The “big picture” perspective of DA as configuration helps therapists begin to make sense of initially baffling thoughts, feelings, and ways of relating. As therapists learn to recognize various pathogenic processes stemming from a DA patient’s conflicted intrapersonal and interpersonal interactions, they also develop more effective ways of working directly with the AT survivor’s moment-to-moment experience.

To use a sports metaphor, understanding the DA patient’s “configuration” of internal and external behavior gives the therapist a good seat in the football stadium. This wider perspective enables both therapist and, over time, patient to work with complex, interrelated “processes” that help move the ball downfield. For example, knowing that AT survivors often experience intense fluctuations in arousal when their therapist is more reliably present points the DA/AT-informed therapist toward interventions that help patients restore emotional regulation, strengthen relationships, and enhance their self-esteem. Goal!

Section 2: Clarification and Expansion

While there are several areas worthy of further consideration, we chose to emphasize the distinction between AT as predominantly abuse versus neglect; differentiating developmental failures of integration as contrasted with disintegration; and the relationships between AT, disorganized attachment (DA), and structural dissociation.

Neglect of neglect

There has been a tendency in developmental research, clinical theory, and psychotherapeutic practice to “neglect neglect” (Leeds, 2024; Lyons-Ruth et al., 2024). Farina and Schimmenti (2025a) are to be commended for avoiding that serious omission. Still, their discussion might have benefited, at times, from further distinguishing the effects and treatment of chronic abuse from neglect or “absence”, specifically the caregiver’s failure to see, feel, recognize, respond responsively to, and even delight in the infant and child (Benau, 2022; McLaughlin et al., 2017). For example, the authors write, “The adaptation to attachment relationships with absent, neglectful, suffering, or severely abusive caregivers generates specific mental representations and pathogenic beliefs that usually lead to the typical relational problems affecting people with a history of attachment trauma” (p. 1; italics added). “Mental representations” and “pathogenic beliefs” are typically very different in survivors of neglect versus abuse. For example, patients who report a recurrent fantasy/fear of falling forever and never landing, or who automatically detach or become enraged whenever their therapist has a momentary lapse in attention, may be living with the effects of neglect rather than abuse.

Differentiating AT that is predominantly a consequence of neglect (AT-Neglect) from abuse (AT-Abuse), while recognizing there is considerable overlap (AT-Combined), can also help clarify which caregiver “failures” are more indicative of neglect than abuse. Likewise, distinct clinical presentations and consequences of AT-Neglect versus AT-Abuse often call for different therapeutic responses or approaches (Adams, 2022; Gurevich, 2015). For example, what the authors refer to as attachment phobia and, we would add, attachment overdependence, can best be understood as reflecting different expressions of the shock of unbearable aloneness (Corrigan et al., 2025), including cephalic shock, abandonment shock, and potential shock (Adams, 2022). Further, understanding that the recurrent shock and pain of early developmental caregiver absence impacts deep brain structures, such as the hippocampus (Dimitrova et al., 2023) and brainstem (Corrigan et al., 2025), has significant clinical implications, as mentioned in Section 3.

“Failure to integrate” versus “disintegration”

The authors wisely refer to research and clinical observations demonstrating chronic deficits in integration. This is particularly true as a result of “absence” (Farina & Schimmenti, 2025b). More importantly, in several instances, they discuss the psychological process of “disintegration,” but do not always clearly differentiate this from a developmental failure of “integration” in the first place. For example, the authors described “neuroscientific investigations have consistently demonstrated direct links between maternal sensitivity and the establishment of optimal connectivity among distinct brain regions” (p. 18); and “mental functions that rely on sophisticated mental integration… [are] especially vulnerable to traumatic disintegration” (p. 18; italics added). They do discuss how “diminished integrative capacity developed during childhood disrupts the coherence of self-experience and the continuity of self, as well as the organization of mental states” (p. 18), the latter presumably referring to structural dissociation. However, what they do not appear to clarify is that, when in development, particularly in cases of severe abuse and, we believe, even more so in neglect, there is a failure to integrate, both at the level of the brain (Lyons-Ruth, 2003; Lyons-Ruth et al., 2023) and with respect to a sense of self (Ogawa et al., 1997). Likewise, while the authors mention that “…extensive research indicates that functional connectivity further deteriorates following emotional stress or activation of traumatic memories” (p. 19; italics added), they do not describe explicitly how deterioration may, in fact, reflect a failure to develop, from the start, sufficient mind/brain organization. For example, there is some research to suggest, including by Farina & Schimmenti (2025b), that chronic neglect impacts integrative capacities cognitively (Lyons-Ruth et al., 2023) and emotionally, both in terms of various indices of dysregulation (Hildyard & Wolfe, 2002) and chronic shame states (Benau, 2022; Wille, 2014).

Attachment trauma, disorganized attachment, and structural dissociation

In the context of clinical conceptualization, the authors make a key statement when they propose that AT does not overlap with disorganized attachment (DA). They join many sources that, following Holmes et al. (2005) and Brown (2006), differentiate between states of detachment and dissociative compartmentalization¹. While these resources also regard detachment as dissociative, we assume that the authors' decision not to use this adjective with detachment is a reflection of older views on dissociation (cf. Van der Hart & Dorahy, 2023), which only regarded compartmentalization or, as we prefer, structural dissociation of the personality, as dissociative. However, conceptually speaking, we consider detachment as dissociative when it pertains to a dissociation between an observing dissociative part (“out of the body”) and an experiencing dissociative part (e.g., Steele et al., 2023; Van der Hart, 2021). Why, then, do we also have some objection to the term compartmentalization? We believe that it implies the existence of rigid boundaries between dissociative parts or self-states, which we do not find in clinical practice, where the dynamic, biopsychosocial system of the personality to which these parts belong is quite dominantly present. In other words, dissociative parts and their mutual relationships are dynamic and capable of altering and creating new arrangements among them. This is also what therapy with dissociative clients aims at. Likewise, stating that dissociative parts or self-states are separate from each other may not be entirely accurate, as they are typically not fully distinct. They have permeable boundaries and may overlap with each other.

This conceptual discussion about the nature of dissociation is essential in a meaningful dialogue on the nature and relationships between AT, DA, and trauma-related dissociation of the personality. The authors state (Farina & Schimmenti, 2025a, p. 11) that although the constructs of AT and disorganized attachment (DA) are firmly related, they do not overlap and need to be distinguished. One reason is that DA is a construct originating from a research paradigm, referring to observations of children exhibiting inconsistent patterns of approach toward their caregivers during the Strange Situation Procedure (SSP). “This construct was later applied to states of mind in adults during the Adult Attachment Interview (AAI; Main et al., 2003).” Most importantly, the authors assert that “the pattern of DA behaviors… suggest[s] the involvement of multiple, disjointed centers of initiative and meaning,… none of which are integrated with one another into a cohesive resolution (Liotti, 1992; Main & Hesse, 1990; Main & Solomon, 1986) (p. 12).” They then state “that the mental state of children with DA during separation from and reunification with their caregiver resembled the freezing response characteristic of passive defense and dissociative states observed in adult patients.” They refer to “deeply conflicting internal working models of attachment,” concluding that “[t]hese contradictory representations are posited to serve as a precursor to dissociative compartmentalization (Dutra et al., 2009; Liotti, 1992; Ogawa et al., 1997)” (italics added).

These understandings, previously presented in the existing attachment literature, are quoted by the authors with some agreement. Several reactions are possible. The first one, with which we agree, is the sole use of the term “dissociation” in the sense of compartmentalization or division of the personality. Or do we misread the authors, and does their use of the term “dissociative states” refer to something else? And when they state that DA can be likened to a form of early traumatization, why don’t they say that DA is a manifestation of AT, even though the origins of the terms are different? And why is DA, with its “deeply conflicting internal working models of attachment,” a precursor of the existence, at young adult age, of dissociative compartmentalization or structural dissociation of the personality? We believe it is more likely that many of the dissociative parts in adults existed already, in less complex forms, in childhood.

We contend, then, that DA is a manifestation of an underlying structural dissociation of the personality. Instead of DA standing for disorganized/disoriented attachment, we believe it should stand for dissociative attachment. Regardless of labeling, both overlook an essential aspect, namely, the defensive component of such behavior. The disorganized aspect refers, basically, to alternations between attachment and defensive behaviors and their related motivational systems, often involving different types of dissociative child parts, as frequently observed in clinical practice. Whether “disorganized”, “dissociative”, or a better term for this process, we believe the most helpful description needs to include the defense component.

Section 3: Continuing the conversation

Given the limitations of space, the authors are to be praised for presenting a clinical vignette demonstrating some of their conceptualization and psychotherapy with a survivor of AT, with a special focus on the seven pathogenic processes explored earlier. We welcome a fuller discussion, perhaps in their future book (?!), that demonstrates some of the many ways their rich understanding of AT can be fruitfully applied clinically.

Still, we cannot refrain from asking one question here. As the authors know, in the field of trauma-related dissociation, the standard of care is POTT (phase-oriented trauma treatment; ISSTD, 2011). These treatment phases are not linear, but are often alternated or seamlessly interwoven after an initial period of stabilization, depending on the needs of the patient (Courtois, 1999; Van der Hart et al., 2006). Now, the authors do not limit the pathological effects of AT to the dissociative orders, which may be a complication, but still, how does their treatment model relate to a flexible application of POTT?

We also propose that further attention in research (Kearney et al., 2023) and practice (Corrigan et al., 2025) be devoted to the impact of neglect or chronic, early developmental “absence” on the brainstem. As the authors observe, current attachment and clinical measures have significant “limitations in assessing preverbal, forgotten, or biased childhood experiences and memories” (Bifulco & Schimmenti, 2019, p. 14). Even more challenging than documenting the effects of preverbal or nonverbal AT is psychotherapy with adults who experienced developmentally early caregiver “absence of presence” or the chronic effects of “what didn’t happen that should have”, i.e., the caregiver’s failure to meet species-expectant experience (McLaughlin et al., 2017) and universal attachment needs. This is particularly true when there is no evidence of abuse, and the patient has little to no idea why they experience profound shame states (Benau, 2022; Wille, 2014) and related ongoing struggles in intimate relationships.

Corrigan et al (2025) have developed a therapeutic approach called Deep Brain Reorienting (DBR) that, based upon clinical observations of one of the authors (Benau) is particularly well-suited to work with the shock of unbearable aloneness pain. Founded upon an understanding of deep brain structures, specifically the midbrain of the brainstem, the creators of DBR have developed a therapeutic methodology that, when effective, ameliorates the long-term consequences of AT-Neglect that might otherwise be unreachable, or altered only after long-term, attachment-oriented, psychodynamic psychotherapy.

We look forward to learning how Farina and Schimmenti incorporate previous descriptions of POTT with their AT model, as well as very recent clinical observations and research into the brainstem (Kearney et al., 2023), with their understanding of AT-Neglect. The rich conceptual and clinical foundation they have provided their fellow researchers and psychotherapists, here, puts them in an excellent position to do just that.