Conducting Effective Therapy for Attachment Trauma Requires Skill in Being Human

Abstract

Benedetto Farina and Adriano Schimmenti have synthesized the burgeoning literature on attachment trauma to draw attention to its prevalence and pervasive role in the development of diverse forms of severe and chronic psychopathology. These sequelae call for a multidimensional approach to treatment that is evidenced by a spate of trauma-related psychotherapies as well as biological interventions. While respecting the sheer complexity of attachment trauma, this commentary offers an integrative perspective for therapists of different orientations. Relying on decades of research on contributors to the effectiveness of psychotherapy, the author provides a distinctive view of the role of common factors that cut across the wide varieties of therapy. These factors pertain largely to qualities of patient-therapist relationships that are especially crucial in the treatment of attachment trauma. This commentary highlights five such common factors: attachment, mentalizing, trust, care, and—not least—the therapist. As Farina and Schimmenti’s review attests, understanding the complexity and severity of illness associated with trauma requires a great deal of knowledge; concomitantly, establishing therapeutic relationships requires an exceptional level of interpersonal skill: skill in being human, to put it simply.

In the mid-1980s I had been practicing in a longterm psychiatric hospital for a decade when a group of us clinicians began to appreciate what Benedetto Farina and Adriano Schimmenti (2025) have summarized so masterfully: the pervasive contribution of trauma in early attachment relationships to diverse forms of chronic and severe psychopathology. In the 1980s, despite our extensive education and clinical experience, we had little knowledge about trauma and its treatment. We were not alone in the field of psychiatry in our limited understanding. We decided to create a specialized longterm inpatient treatment program, and this provided me with an opportunity to conduct diagnostic psychological testing, psychotherapy, and research. Somewhat fortuitously, I was invited by my colleagues to develop a psychoeducational program for patients that became like a seminar in which we all learned together. After several years of doing this work, I wrote what amounts to a textbook for patients, Coping with Trauma (Allen, 1995, 2005). I summarized what I had learned from clinical work and scouring the literature, but I had learned most from the patients, who graciously educated me about their traumatic experience and their daunting efforts to heal. As Farina and Schimmenti’s synthesis indicates, the field of attachment trauma has burgeoned since those early days, but treating these patients remains as challenging as ever.

Combining their scholarship and clinical experience, Farina and Schimmenti have given us a crash course in attachment trauma, leaving no stones unturned in their extensive review. I have nothing substantive to add to their account but rather will respond to their generous invitation to provide some commentary by articulating a broad perspective that is based on my four-decades-long concern with trauma. I agree wholeheartedly with Farina and Schimmenti’s advocating a transtheoretical and transdiagnostic approach. I think we also need the equivalent of a trans-psychotherapeutic approach that has been developing since the 1980s under the rubric of psychotherapy integration (Norcross & Goldfried, 2019). Above all, we need flexibility and open-mindedness along with a lot of common sense.

Here is the essence of trauma treatment: In the context of talking about posttraumatic flashbacks, I once said to a patient-education group, “The mind can be a scary place.” A young woman in the group responded immediately, “Yes, and you wouldn’t want to go in there alone!” I find her pithy comment especially apt inasmuch as I have long thought about the essence of traumatic experience in attachment relationships as feeling alone and invisible in the midst of pain and suffering (Allen, 2001). To be abused is also to be emotionally neglected—your humanity invisible. We must cultivate a feeling of connection (Allen, 2025).

Common relational factors in psychotherapy

The healthcare system in the U.S. is dominated by “evidence-based” therapies, specialized procedures designed to treat codified psychiatric symptoms and disorders. To a point, this practice is reasonable, but it is also constraining. We now have hundreds of brands of therapies with enormous resources invested in comparing their relative effectiveness. Nearly a century ago, a young psychologist at Harvard University, Saul Rosenzweig (1936), proposed that what various theories and methods of psychotherapy had in common was more important in their effectiveness than the differences among them. A couple of decades later, psychiatrist Jerome Frank (1961) made a comprehensive and persuasive case for the over-riding importance of common factors among psychotherapies. These common factors pertain largely to the quality of the patient-therapist relationship. Rosenzweig and Frank were prescient: Decades of research now attests to the predominant role of therapeutic relationships in the effectiveness of psychotherapy (Norcross & Lambert, 2019; Wampold & Imel, 2015). Accordingly, while acknowledging the need for conceptual frameworks and systematic methods, I have argued that we should shift the balance from continuing to develop specialized therapies to giving more attention to the personal and professional development of therapists (Allen, 2022).

Carl Rogers (1951, 1992), who developed Client-Centered Therapy and pioneered psychotherapy research, proposed three necessary and sufficient conditions for effective treatment: the therapist’s empathy, positive regard for the patient (acceptance), and genuineness − all of which have been shown by research to be significant contributors to treatment outcomes (Norcross & Lambert, 2019). The therapeutic alliance, combining collaboration on treatment goals with an emotional bond, is the most extensively researched common factor in the psychotherapy research literature (Wampold & Flückiger, 2023). Another line of research shows substantial individual differences among therapists in their effectiveness (Castonguay & Hill, 2017), likely associated with their skill in cultivating therapeutic relationships. But I have argued that this research literature is misleading in construing the therapeutic relationship as a means to an end, as if we must develop a positive relationship to conduct the real work: whatever brand of therapy, methods, or techniques the therapist employs. On the contrary, especially in working with patients who have been traumatized in attachment relationships, the real work of therapy—its ultimate aim and outcome— is promoting the patient’s capacities to form close emotional connections in relationships with persons in their life (Allen, 2022, 2025). I once said to a group of patients that psychotherapy should be a bridge to other relationships and that, with a history of trauma, it can be difficult to get on the bridge. A patient wisely replied that it’s even more difficult to get off the bridge (Allen, 2001). I now argue that group and family therapy, along with therapeutic communities, are valuable in bringing others onto the bridge.

Think back to Rogers: Ideally, patients will form relationships with persons who are empathic, accepting, and genuine. Moreover, patients also will become empathic, accepting, and genuine in their relationships. Consider the therapeutic alliance: All of us benefit from the capacity to form emotional bonds that promote cooperation on goals. We can think of psychotherapies of various types as cultivating these relational capacities in a way that benefits patients’ current and future relationships. In what follows, with treating attachment trauma foremost in mind, I propose four relational domains that we might think of as common factors in trauma therapies: attachment, mentalizing, trust, and care. None of these four, however, has been incorporated into the canonical lists of common therapeutic factors (Norcross & Lambert, 2019). Attachment and mentalizing have been well researched, but trust and care have been comparatively neglected in the professional psychotherapy literature while being well represented in scholarly literature in the humanities (i.e., philosophy and ethics). I conclude this section by adding a much-neglected fifth common element: the therapist.

Five uncommon common factors

To my knowledge, no one has suggested that we think of attachment as a common factor in psychotherapy. Granted, for many patients without significant problems in relationships who easily form therapeutic connections, attachment might not play a significant role in the treatment. For patients with a history of trauma in attachment relationships, however, attachment will be a common factor that cuts across diverse therapeutic approaches. John Bowlby (1982) developed attachment theory from an evolutionary perspective, arguing that we mammals developed attachment strategies to provide safety and protection under threatening conditions − separation distress prototypically. For us humans (and probably many animals), attachment provides a feeling of security (Sroufe & Waters, 1977). On the basis of her observations of mothers and infants, Mary Ainsworth (1963; Ainsworth et al., 1978) added that the safe haven of attachment also provides a secure base for exploration. In a “circle of security” (Marvin et al., 2002) that balances separation with reunion, the infant confidently explores the environment knowing that, if endangered or hurt, protection will be forthcoming. In his book on psychotherapy, A Secure Base, Bowlby (1988) added that the safe haven of security also frees the patient to explore the inner world. As the patient in my trauma education group exclaimed, “You wouldn’t want to go in there alone.” Ainsworth (Ainsworth et al., 1978) associated secure attachment with the caregiver’s sensitive responsiveness, which I construe as the common therapeutic factor in therapy for attachment trauma.

Peter Fonagy (1989) introduced the concept of mentalizing into our professional literature in the context of treating patients with borderline personality disorder. I think of our skill in mentalizing as using commonsense psychology, as we begin learning to do in early childhood − to the extent that our caregivers are mentalizing in relating to us (Allen, 2025). Mentalizing begets mentalizing and secure attachment, and failures in mentalizing beget failures in mentalizing and disorganized attachment; such failures are prominently associated with attachment trauma, as Fonagy and colleagues began demonstrating decades ago (Fonagy et al., 1991). Based on a scientific assessment of our commonsense psychology, Anthony Bateman and Fonagy developed a manualized treatment for patients with personality disorders that has been supported by randomized-controlled trials (Bateman & Fonagy, 2016); their Mentalization-Based Treatment approach is now being extended into other psychiatric conditions (Bateman & Fonagy, 2019). My primary interest has been in mentalizing as a common therapeutic factor (Allen & Fonagy, 2019; Allen et al., 2008); no therapy − including behavior therapy—could be conducted without the therapist and patient being engaged in mentalizing. Among the most heartening treatments are those promoting mentalizing in at-risk mothers of infants, exemplified by Arietta Slade and colleagues’ Minding the Baby program (Slade et al., 2023). These early interventions interrupt intergenerational transmission and disorganized attachment. To me, the connotations of “mentalizing” are too cognitive and intellectual; with Ainsworth in mind, I like the amalgam of sensitively responsive mentalizing.

I find it puzzling that therapists agree on the centrality of trust in psychotherapy, but we seem to take our understanding of trust for granted and neglect considering what would make us trustworthy (Allen, 2022). Fonagy and colleagues (Fonagy et al., 2017) are exceptional in highlighting the importance of epistemic trust, that is, trust in the accuracy and relevance of knowledge being communicated. Epistemic trust is essential for social and cultural learning. I emphasize what Erik Erikson (1963) called basic trust as the first stage of development, with maternal care of infants as its prototype. Trust and trustworthiness must be reciprocal; therapists treating patients with a history of attachment trauma must become trustworthy over the course of the therapy; and patients also must become trusting and trustworthy in therapy as well as in their relationships beyond therapy. Yet, rather than trusting in general, patients must be discerning in trusting others— especially when they have been traumatized. With a trauma history, distrust is reasonable, but patients often are missing the opportunity to trust persons who are trustworthy. They can begin doing so in relationships with therapists who are trustworthy. This reciprocity in trusting and trustworthiness often will be long in coming, an optimal outcome of therapy rather than a precondition for it.

With basic trust in mind, I argued that trustworthiness − in therapy and more generally − requires a combination of care and competence (Allen, 2022). In doing so, I complained that therapists have not given trust its due. Unwittingly, I had done something similar in taking my understanding of care for granted. Belatedly, I discovered a rich philosophical literature on care and wrote about that (Allen, 2025). I distinguish broadly between caring feelings and caregiving actions, the former motivating the latter. The attachment literature focuses more on action than feeling, and I highlight the significance of feeling connected. Like trusting and trustworthiness, reciprocity looms large in care: To be effective, care must be met with responsiveness to care. Commonly, patients with a history of attachment trauma are distrusting of care and unresponsive to therapists’ caring feelings and actions. We all naturally expect that conscientious and competent efforts to care will be met with appropriate responsiveness, and we therapists are prone to feeling frustrated and demoralized when these efforts fail. At times, we must persist in caregiving when we struggle to feel caring. As it is with trusting and trustworthiness, rather than being a precondition, caring and responsiveness to care will be the hard-won, optimal outcome of therapy − to the extent that it generalizes to patients’ other relationships.

Albeit unique to each therapy, the therapist is the commonest of common factors (chatbots aside). Research has shown substantial individual differences among therapists in effectiveness, especially in the treatment of more severely ill patients (Barkham et al., 2017). David Orlinsky and colleagues (Orlinsky et al., 2005) conducted a highly informative multidisciplinary and multinational study of 12,000 therapists. Crucially, Orlinsky took a developmental approach that assessed therapists’ experience in their family of origin, their current close personal relationships, and their relationships with their personal therapists. This complex study defies simple summary, but the gist of the results warrants our attention. Therapists’ family relationships, personal relationships, and relationships with their therapists influence the quality of their relationships with their patients. Most therapists (80%) have been in personal therapy, and the overwhelming majority of those feel they benefitted from it. About 75% of therapists generally experience their relationships with patients as being caring and fulfilling; of the 25% who felt unfulfilled, some were feeling disengaged and others felt troubled. These unfulfilled therapists were less likely to have had personal therapy. Orlinsky’s research buttresses my view of the fundamental importance of therapists’ personal relational development— beginning in infancy at the preverbal level—on which their professional development is superimposed. Of course, this personal development continues alongside professional development, and we might hope that there is a positive synergy between these two developmental planes.

To recap: Patients who have been traumatized in attachment relationships must heal by forming secure attachment relationships, mentalizing their traumatic experiences, trusting their therapist, and responding to care. Accordingly, impaired in all these domains, they must do what they are least capable of doing. This dilemma is the bane of conducting psychotherapy. Yet, as long as they are living − sometimes despite themselves − our patients are not incapable of healing. But they cannot do it alone. And we therapists will rely heavily on our ongoing personal development, much of it with help from our patients and our struggles with them.

Skill in being human

A decade ago, protesting the seemingly endless proliferation of psychotherapies and the horse-race mentality driving research, I declared myself a practitioner of plain old therapy in treating trauma in attachment relationships; from a humanistic perspective, I proposed that the skill we need is “skill in being human” (Allen, 2013, p. 212). Here is an example, the first paragraph from Farina and Schimmenti’s case example, which I take the liberty of quoting at length:

Anna was 38 years old, with a solid career and a wedding on the horizon. A woman who, from the outside, seemed to have arranged the pieces of her life with precision, like a carefully set dinner table—elegant, functional, without a single misplaced fork. And yet, something trembled beneath the surface. She had come to therapy for an anxiety that clung to her skin like damp fabric, and a sadness that sat in the hollow of her chest, as if someone had left a door open inside her, letting the wind blow through.

This is the kind of sensitively responsive understanding we need − poetry, disguised as prose.

We therapists are now easily cowed by the prestige and hegemony of science and the demand for precision in scientific language, which has spawned a spate of professional jargon. This is not the language of ordinary psychotherapy. I counsel young therapists: If you speak and write in plain English, you will help your colleagues understand patients and you will impress no one. I have been enamored with science and engaged in research throughout my career, with a major emphasis on evaluating the effectiveness of treatment (Allen et al., 2017). But I now protest scientism: Science’s majesty does not entitle it to a monarchy (Allen, 2023). I think that, in the field of psychotherapy, science should be conducted in the service of humanism. In the modern West, we have merely a century of psychotherapy as contrasted with seven centuries of humanism (Bakewell, 2023). We need better balance, and the extant research on common factors points in the right direction.

In sum, the flow of this commentary follows my professional developmental trajectory. I learned about Carl Rogers in the 1960s as an undergraduate student majoring in psychology, and I began conducting research on the therapeutic alliance in psychotherapy and hospital treatment the 1980s (Allen et al., 1988; Allen et al., 1984). Around the same time, I developed an interest in attachment theory and research as we began to specialize in trauma treatment. After working with Peter Fonagy for several years, I came to think of mentalizing − our ostensibly distinctive human capacity − as the most fundamental common factor (Allen & Fonagy, 2006). In recent years, I construed trust as more fundamental and then came across philosopher Virginia Held’s (2006) assertion that “Care is probably the most deeply fundamental value” (p. 17) inasmuch as none of us would survive without it. “More fundamental” and “most fundamental” are awkward phrases. Do all these proposed common factors vie for priority? What about love? Compassion? Respect? Wisdom? Mindfulness? One of my early mentors, Peter Novotny, counseled: “When you don’t know what to do, be kind”. You can think of other values and your own priorities; take your pick. In principle, we could measure all these concepts precisely and subject them to a factor analysis. Perhaps they’d all load most strongly on one common factor, which we might call human goodness − vague as can be, but the antidote to attachment trauma.