Attachment-Based Therapy: Helping Clients Actually Change, with Dr. Amir Levine
with Dr. Lisa Marie Bobby and Dr. Amir Levine
Why Your Insight-Trained Clients Still Aren’t Changing
Insight is not the lever. Adult attachment patterns persist because they are working models — and what rewires them is repeated lived experience of safety, not understanding.
By session four of the day, the client across from you can name their attachment style. They can describe the childhood wound. They can articulate their defense pattern in language you would use in supervision. And every few months, they are processing another version of the exact same painful cycle in their relationship.
If you have ever sat with a client like that and quietly wondered what you were supposed to do with this, you are not alone. It is the central frustration of working with attachment-disrupted adults: the gap between the insight a client can articulate and the patterns they actually live in. Attachment-based therapy is meant to address exactly that gap.
In this episode, I sit down with Dr. Amir Levine — Columbia psychiatrist, molecular neuroscientist, and author of Attached (3M+ copies sold) and the new follow-up Secure: The Revolutionary Guide to Creating a Secure Life. We walk through his Secure Priming Therapy model, the CARP framework, the SIMIs concept, and the specific clinical interventions he has built for anxious and avoidant clients. This is the conversation therapists have been asking for.
“The brain takes in information that already suits its beliefs.” — Dr. Amir Levine, Columbia University
Moments from this episode
Episode transcript
Dr. Lisa Marie Bobby: I am here today with a personal hero, Dr. Amir Levine. You are probably already so familiar with his work. I don’t think there’s a therapist listening to this conversation who does not have this specific book in their office, Attached: The New Science of Adult Attachment, which came out a while ago. And ever since then, our clients are coming in wanting to talk about their attachment styles or that of their partners, always followed up with, “So what do I do to create more security?” And Dr. Levine has been hard at work for the years since Attached came out on a new book called Secure that answers some of those questions.
Dr. Amir Levine: Initially after I wrote Attached, people started coming and saying, “Hey, help me become more secure.” And I didn’t have an immediate answer for that, because these attachment styles, they were not part of the clinical, at least in adulthood. And I started to think how to help people become more secure. I found a lot of the answers in another line of work that I have, which is I’m also a molecular neuroscientist. I started to think how to help people become more secure, and I found myself all of a sudden diverting from the usual therapeutic back and forth and explaining patients more and more about their social brain and how the social brain works. From that came all the different tools and this really approach that I’m now using, which I call secure priming therapy. This new book, Secure, describes it in detail.
Dr. Lisa Marie Bobby: So you’re a physician, you’re a psychiatrist. Help us understand what you experienced with more traditional therapeutic techniques that didn’t quite cut it when it came to helping people develop a more secure attachment style.
Dr. Amir Levine: That’s exactly what I was thinking. How do I help people become more secure? Even traditional therapy has moved a lot — even traditional Freudian therapy now focuses more about the relationship between the therapist and the client. We know about the transference and countertransference. But just like working as a neuroscientist and looking how the brain changes, I started to realize that our brain is so socially savvy and that that one hour and creating that model of a relationship — a secure relationship with my patients — as good as it is, may not be enough. I really wanted to immerse them in a secure environment. So I started to set out the therapeutic hour to create that secure relationship, but also to teach them how to seek out and rework their social habitat to something that’s more secure. That took me a while to work up all the tools, but that’s the main goal of secure priming therapy.
Dr. Amir Levine: If you think about it, classic psychoanalysis happened four times a week, not once a week. So that one-hour therapeutic hour needs a lot of secure input in order to change. What attachment styles are, they’re really working models. It’s a set of expectations and ideas about the world that reinforce themselves. The brain is very savvy. It takes in information from the environment, but it’s very selective in the kind of information that it takes in. It takes in information that already suits its beliefs. So if you’re anxious, you think, “Oh, people are gonna hurt me. I can’t trust people.” It will dismiss evidence to the contrary and look for evidence to what it believes in. We may need to give the social brain tools to discern between secure and insecure interactions, and know how to find and cultivate more secure interactions.
Dr. Lisa Marie Bobby: A clinical hour with us once a week is not enough to budge this. We need to construct a much more powerful encompassing experience that starts to rewire the brain, using our therapy sessions as a way of helping clients have those experiences outside of the office.
Dr. Amir Levine: For example, the brain is very sensitive to exclusion. There’s been this huge body of work that I really talk about in the first chapter. It’s based on the Cyberball experiments, the Cyberball effect, that shows how harmful exclusion is to the brain. Areas of painful distress and self-scrutiny light up when people have been put in functional MRI machines while they went through the Cyberball paradigm. You play catch with two other people. It’s like a rudimentary video game, and all of a sudden they stop throwing the ball in your direction. Areas of distress and self-scrutiny come online, and people report feeling less self-esteem, less in control of their lives, that their lives are less meaningful.
Dr. Amir Levine: When I say self-scrutiny, like “What have I done wrong? Am I good enough? Where is this going?” So all of a sudden you don’t get a text or people don’t invite you to something, and it has such a profound effect on you. And the opposite is true. When you’re hyper-included, you feel more self-esteem, more in control of your life, that life is more meaningful. It quiets the brain. These are things we deal with our patients all the time. By increasing their hyper-connectedness, we can provide them with so much psychological benefit. For me, it’s hard to send patients into this cruel world. I can be very nice to them in the session and very warm and loving, but then they go out into a world that has thousands of social interactions in between our sessions that are going to undo a lot of what we’re doing.
Dr. Lisa Marie Bobby: I love this really compassionate approach. You’re a scientist, you’re a researcher, and you’ve spent so much time going into the what is going on in a way that helps people understand, but then carrying it forward into the how do we actually start to resolve this is the zillion dollar question.
Dr. Lisa Marie Bobby: What I understand about this model you’ve been developing is that it is actually like a 16-session framework. Conventional wisdom when it comes to attachment issues, it’s maybe years, if ever. So is it actually rewiring someone’s relational patterns, or is it giving them tools and skills to show up differently?
Dr. Amir Levine: It is a 16-session therapy course. It has both the manual for the therapist and an accompanying guidebook for the client. It’s both therapy and coaching. You go through the session stage by stage. The introductory session talks about how our attachment styles can change, how we don’t have the same attachment style with everyone around us — we have different attachment styles with different people. Also looking at the angels in our life, not just the ghosts in our nursery. There’s a paper called “The Angels in Our Nursery” about the people who have done us good as kernels of security.
Dr. Amir Levine: Then the next session goes into what the problem is. The problem is that Cyberball effect — that feeling of being disconnected, excluded, ignored. From an attachment perspective, it’s more feeling disconnected. Our brain loves feeling connected. The therapist asks, “Let’s look at areas in your life when you feel this exclusion or disconnect. How does it show up?” Usually I hear from patients, “I shouldn’t let this get to me. So what if my boss didn’t include me in this work call?” But that doesn’t align with our brain. If you read the chapter about Cyberball, our brain can’t help but feel that. It’s almost a reflex.
Dr. Amir Levine: Then I don’t just leave them. I give them the tools to create a hyper-connected life. We walk through each session, and you achieve a different goal, showing up differently to your social milieu, restructuring it to create a more secure one. It’s divided into three parts.
Dr. Lisa Marie Bobby: One thing that comes up for me as a psychologist is that there absolutely are attachment disorders — early childhood experiences, often very adverse, that create hard-coded responses. Would you say your approach is geared toward treatment of someone with a historical reactive attachment disorder diagnosis, or is this more general population, how can we all feel safer in our relationships?
Dr. Amir Levine: What I love about this approach is that we’ve all been there — difficult relationships, same patterns that repeat themselves, same arguments, same feelings. At the heart of this work is the idea that there is a different attachment logic. Attachment has a very different logic than the way we usually think about things. It’s a pre-language logic. It has to concentrate on safety, not about who’s right and who’s wrong. It’s about feeling safe by feeling connected. Once you know how to use the attachment logic, you can change the way you’re dealing with relationships to get away from a lot of these recurrent patterns.
Dr. Amir Levine: One of the tools I use all the time is what I call the five pillars of the secure life, or secure mode. The acronym is CARP. If you want to be secure, it’s a very simple way of relating to the world. You have to be Consistent, Available, Responsive. But it’s not enough that I feel “Wow, I’m so great. I’m consistent, available, responsive.” It’s a relationship model, so you have to make sure that the other person experiences you as Reliable and Predictable. Consistent, Available, Responsive, Reliable, and Predictable — CARP. That’s the key to living a more secure life. It sounds simple, and it is simple in a way, because attachment is a simple neurocircuitry. It’s all about safety and that continuous back and forth between people.
Dr. Lisa Marie Bobby: Take us more deeply into what this looks like. So you have a client, say, who historically feels anxious in relationships. Then what does this work look like for them? Not just your one-on-one sessions, but the things that you are helping them do out in the world so they can have more of these CARPy experiences with other people.
Dr. Amir Levine: Say someone with an anxious attachment style comes to treatment. The first part of the treatment is to teach and to learn — it’s much more than psychoeducation, because it challenges a lot of current beliefs. You learn about the Cyberball effect, you learn about CARP. And you learn another term: that a lot of the change happens not from big discussions of things that happened in childhood. A lot of it is a here-and-now treatment, and we focus on what I’ve come to call the seemingly insignificant minor interactions of everyday life. So we have CARP, and we have SIMIs — the seemingly insignificant minor interactions. Because people think a lot of the change comes from big things, but actually our brain monitors the little interactions that happen.
Dr. Amir Levine: I teach people to look at those CARP SIMIs and start looking for them and understand. Then I ask them to take a questionnaire I’ve adapted, to really find out what their attachment topography is.
Dr. Lisa Marie Bobby: Which questionnaire do you use, or is this one that you’ve developed? I’ve had a hard time finding a good assessment for this.
Dr. Amir Levine: I like the one I’m now doing research on to develop. You get an attachment topography — you don’t get one attachment style. There’s a drop-down menu where you can choose your partner, your coworker, your boss, a friend, a sibling — all the important people in your life. You get a map of what your attachment style is with each and every one, as well as a general attachment style. The research actually shows that we don’t have one attachment style. We have an attachment topography. Once we have that topography, we use it as a vehicle for greater change because we look at who shows up that you can be secure with, and who actually pulls you out of secure mode.
Dr. Lisa Marie Bobby: If an attachment style exists within us and this is how we show up regardless of the relationship, that would be one thing. Versus — what I think you’re saying is that this assessment measures the safety of that specific relationship. From emotionally focused couples therapy, we know that people in distressed relationships tend to start showing up in pursuit-y or avoidant ways because the relationship is distressed, not necessarily their own intrinsic attachment style.
Dr. Amir Levine: The latest research shows that our social brain is much more flexible than we initially gave it credit for. Which is actually good news, because then we can mold it and shift it. We have an internal assessment that in certain situations will show up in different ways. People who are more insecure tend to flip between pursuer and avoidant. But secure people tend to be pretty stable. They can withstand a lot of what’s coming at them. Something unique also happens in the space between two people. Each relationship brings an opportunity. We can look at which relationships you have, how you show up for them, how they show up for you, and use that to restructure how much emphasis you put on different relationships in order to shift you away from insecure patterns toward a more secure mode.
Dr. Amir Levine: So for someone who’s anxious — when you read the chapters, you see that each attachment style also comes with its own merits. It’s not just something bad, it’s something we’re programmed through in evolution. People with anxious attachment have a sixth sense for seeing things and perceiving things in the environment that other people can’t. The research shows that again and again. It’s an amazing tool to perceive things others can’t see, but it comes at a price — you’re more sensitive to the environment. So if you’re more sensitive to potential disconnect, then even more so we have to make a hyper-connected world for you a priority.
Dr. Amir Levine: I encourage people with anxious attachment to do what I’ve come to call a CARP intervention. It’s very simple. You don’t start to tell them how much they’ve hurt you. You just say, “You know, I just learned this new thing about the brain. The brain doesn’t like exclusion. It doesn’t like disconnect. And for me, it’s actually very important. I aspire to be more CARP, and I’m looking for other people in my life to be that way too — to be consistent, available, and responsive.” It doesn’t take much. A little bit goes a long way when it comes to attachment. You invite someone to join their secure village. If they join, great — you have a new secure recruit. If they can’t, what I teach is to reprioritize relationships.
Dr. Amir Levine: Anxious people are also fixers. Part of what we teach is: you don’t need to fix this person. You need to make sure your brain is protected. So instead of texting this person, text the secure person. Give them more priority in your life. Here I have another tool, a set of tools called Wall Tennis With Love. You’re basically the wall. Whatever the other person sends in your direction, you reply back with love. But you don’t initiate. So if I have a friend who, when I used to call and try to share something troubling, wouldn’t really listen — now with Wall Tennis With Love, I will never call this friend and share my difficulty. I have other people in my life that are superb at that. It’s not a punishment. You maintain connection with them, but you right-size the relationship and reprioritize other relationships.
Dr. Lisa Marie Bobby: So important — because in my experience, when someone has an anxious attachment style, the narrative is “it’s something about me and how they feel about me specifically, and I’m gonna make them love me.” And what you’re saying is, no, some people are actually more available and better matches for you than others. Disconnect the personalization and make decisions accordingly.
Dr. Lisa Marie Bobby: Tell us a little bit about how this looks if you have somebody coming in. Do you have people who are self-proclaimed avoidant attachment style type people coming in saying, “Dr. Levine, I have a problem. Help me fix this”?
Dr. Amir Levine: Yes, they do come to treatment. I have to say, this new book Secure is my way of making amends to the avoidants of this world. When we wrote Attached, all I had to go on was the research articles, and even those are a little biased in the way they look at avoidance. But then I started to work more closely with people who have an avoidant attachment style, and their plight is real. They do suffer, because they also want connection, and it keeps not working. It took me a long time to come up with specific tools to help them, but I did.
Dr. Amir Levine: I identified in the chapter for avoidance three specific pitfalls. For someone who’s avoidant, often the issue is not that other people are not CARP with them — it’s that they are not CARP with others. The first pitfall is that people who are avoidant often really take care of their own problems. They’re the minority — about 20% of the population. If they have a hardship, they buckle up and take care of things on their own. So when someone else comes to them — which is the rest of the 70% of the population — they’re like, “What do you want from me? Just take care of it on your own.” But unbeknownst to them, they’re pushing the other person away. When I’m in distress and going to someone for help, and they push me away, I’m gonna forget the original reason and now they become the source of the problem.
Dr. Amir Levine: What I do sometimes in session is show them the Strange Situation test, where you come with a caregiver to a room full of toys and the toddler starts to play. Then they ask the caregiver to leave the room, and immediately the toddler drops everything and runs to the door, crying. I explain: “Look, when you’re not CARP, you’re like the mother leaving the room, creating this horrible reaction that you don’t want.” Even though we’re not children anymore, we have the same neurocircuitry. Attachment works like a thread of connection. When a child plays, they look every once in a while to check that the mom is there. If she’s there, they don’t care about the mom — they care about playing. The mom recedes to the background. So if you want to recede to the background because you need your distance, you’re going about this all wrong, because you’re actually the mother leaving the room and creating a big drama.
Dr. Lisa Marie Bobby: You had termed it secure priming therapy and coaching. I know from my own experience — I am a board-certified coach, and part of my practice is supporting therapists in developing coaching competencies because I believe so strongly in them. But I also was like, “Ooh, I wonder if people are gonna have some feelings about this,” because I think we think of the way to really resolve attachment issues as this deep, dark, super serious therapy. But what you’re describing right now is so darn coachy — where you’re like, “Listen, dude, what you’re doing right now is making it worse. Here’s what to try differently.” That is what coaches do, right? You have a goal of a better relationship, and here are some things to consider changing to get a better result.
Dr. Amir Levine: The coaching part — that’s the third part. It really focuses on real-time interventions. I think coaches do real time. It depends on your level of comfort with people texting you at different times of the day and night. What I’ve found is that you can have all these wonderful discussions in the session. They really understand. Then you send them out into the world and a fight happens, and all of a sudden everything goes out the window. They engage immediately in the same patterns. What I’ve found very powerful is that in the moment, if they can text you and say, “Hey, I’m so upset now with my wife,” you can in real time do secure priming. I give specific examples in Secure, in the book and the manual, how to take them down from that insecure ledge of just blowing up or shutting down — all the things that perpetuate the same patterns. You can really break the patterns by intervening in real time.
Dr. Lisa Marie Bobby: That is powerful stuff. So good. There’s so much to talk about here. I’m so excited about your new theory, and I know it is going to be helpful for so many clients, but also for therapists in creating a structured roadmap for what to do. Because to your point, just talking about this stuff in sessions really isn’t enough to move the needle.
Dr. Lisa Marie Bobby: Before I let you go, could we talk just a little bit about any thoughts or recommendations you have for therapists on how to identify and perhaps manage their own attachment responses that habitually come up? Personal share — I don’t think I’m an avoidantly attached human. There’s nothing in my history consistent with that. However, I’m not a particularly reliable or consistent person. I have ADHD, which makes me forgetful. I also tend to be a very spontaneous person, as evidenced by me emailing you an hour before we did this and asking, “Hey, you wanna do a live stream?” So when it comes to planning in advance, I don’t really love that. As a therapist, do our attachment styles impact that therapeutic relationship?
Dr. Amir Levine: Oh, yeah, of course. In Secure, I bring examples of supervision — struggles that therapists have in therapy with patients and how we do secure priming supervision to help them find their more authentic voice, to learn to live more comfortably with what they’re bringing to the table. There’s a whole part — the last part of the book — that talks about finding your hidden sparks of talent, and seeing how some of what you think are your impediments, in the right setup and environment, can actually be a talent.
Dr. Amir Levine: For us humans, we don’t care so much about what people do. We care about the meaning we assign to their behavior. As long as you want to show up in a way that won’t make others distressed, and as long as you’re trying — that’s actually your CARP intervention. You’re telling people, “Hey, look, this is how I am. I’m gonna try to show up, and if you see that I’m not responding to you, text me three times. It’s fine with me. I don’t mind it.” That’s actually what I usually tell people. You create a very meaningful, different way of interacting with people around you by letting them know, “This is how I am. I want to be there for you. Here are some solutions so we can feel connected and you don’t feel the disruption of our connection. That’s what I’m bringing to the table. I’m here. I’m showing up for you.” That’s what people want.
Dr. Lisa Marie Bobby: I love that. So practical. And so glad to know that you have supervision attached to therapists who are learning and applying this model to support their needs as they practice in this way. This has been so good. Where do we go to learn more — do you have training opportunities for clinicians?
Dr. Amir Levine: You can find everything on my website, amirlevinemd.com. You can do that quiz and get your attachment topography, and there’s a section there for Secure Priming Therapy where you can leave your email. You get a little pamphlet about SIMIs and CARP, and I can reach out to people later and let them know about training when the next one is coming up.
What to take with you
Insight is not the lever.
Adult attachment patterns persist not because they are immutable but because they are working models — sets of expectations the brain reinforces by selectively absorbing confirming evidence and dismissing the rest.
The 50-minute hour is one input among thousands.
A client walks out of session and into a week of social interactions that mostly reinforce the existing model. The work has to extend beyond the room.
Safety, not insight, drives change.
What rewires an attachment pattern is repeated lived experience of being seen, included, and reliably shown up for. The mechanism is accumulated congruent experience, not understanding.
CARP is the operating model.
Consistent, Available, Responsive, Reliable, Predictable — what clients are recognizing in others, recruiting more of, and embodying themselves.
SIMIs are where the work happens.
Seemingly Insignificant Minor Interactions — the small moments of being noticed or excluded — are where attachment patterns actually update. The brain does not need a dramatic corrective experience. It needs many small congruent ones.
The therapist’s own attachment style is doing real work in the room.
Whether or not it is being explicitly tracked, your patterns are showing up. Naming this with supervision, peer consultation, or our community is a clinical practice worth investing in.
Attachment-Based Therapy: Helping Clients Actually Change, with Dr. Amir Levine
By session four of the day, the client across from you can name their attachment style. They can describe the childhood wound. They can articulate their defense pattern in language you would use in supervision. And every few months, they are processing another version of the exact same painful cycle in their relationship.
If you have ever sat with a client like that and quietly wondered what you were supposed to do with this, you are not alone. It is the central frustration of working with attachment-disrupted adults: the gap between the insight a client can articulate and the patterns they actually live in. Attachment-based therapy is meant to address exactly that gap. The question is whether the framework most of us were trained in is doing the work it was supposed to do.
In this episode of Love, Happiness, and Success For Therapists, I sit down with Dr. Amir Levine, the Columbia psychiatrist whose first book Attached has now sold over three million copies and become a permanent fixture on every clinical bookshelf. His follow-up, Secure: The Revolutionary Guide to Creating a Secure Life, just came out from Penguin Random House. It is the book Levine wrote because readers kept coming back asking the question therapists ask in supervision every week: how do I actually help them change?
Most of the clinicians who join our team and our certification programs at Growing Self come in carrying exactly this gap. They have been doing good work. They have insight-trained instincts. And they have watched clients understand themselves more deeply each year while staying stuck in the same relational patterns. The cause is not the clinician. It is not even the client. It is that attachment patterns do not change because a client understands them. They change because a client has a different experience, repeatedly, in a different relational context. That different relational context is the work my team does every week, and what we teach inside the Therapist Growth Collective. What I am going to walk you through in this article is what that actually looks like in practice, with citations to the underlying research and the specific frameworks Levine teaches in Secure that fold cleanly into therapeutic work.
What is attachment-based therapy and how is it different from other approaches?
Attachment-based therapy is a therapeutic modality that uses both the therapy relationship itself and the conditions for security in the client’s life outside the room to help that client shift their core relational patterns toward secure functioning. Where traditional insight-oriented therapy treats awareness of the pattern as the lever of change, attachment-based therapy treats accumulated lived experiences of safety as the lever, and uses the therapist’s relationship with the client, plus the structure of their social world, to deliver those experiences.
The distinction matters clinically. Levine’s research builds on three decades of attachment science, including Mary Ainsworth’s Strange Situation work, which originally identified the three primary attachment styles in infants, and the affect-regulation model that Mario Mikulincer and Phillip Shaver developed for adult attachment. Adult attachment research has consistently shown that attachment patterns persist not because they are immutable but because they are working models, sets of expectations the brain reinforces by selectively absorbing confirming evidence and dismissing disconfirming evidence (Mikulincer & Shaver, 2020). For a fuller picture of how attachment styles map onto present-day clinical work, our earlier conversation with Dr. Dan Siegel on attachment style therapy sits as the foundational companion piece to this one.
What changes a working model is repeated direct experience of something different. Levine’s argument, which he articulated cleanly in our conversation, is that the 50-minute clinical hour cannot supply enough secure input on its own to overwrite a working model that has been reinforced thousands of times across a lifetime. Attachment-based therapy, in his framing, has to do two things at once: hold the secure relationship inside the session, and equip the client to recognize, recruit, and reinforce secure relationships outside it.
This is the part of the work most therapists were not explicitly trained in, and it is where coaching competencies and a structured methodology become genuinely useful. The clinicians on our team at Growing Self are trained as both therapists and credentialed coaches because the work of helping a client restructure their actual relational world between sessions is, in practice, coaching work. It is not a replacement for therapy. It is the second half of the same intervention. If you are wondering where that line sits, our piece on what therapists should know about coaching walks through it in detail.
Why do clients understand their attachment patterns but still can’t change them?
Insight does not change a working model. The brain that has spent decades learning to scan for unavailability or to defensively withdraw cannot be talked out of those scans by understanding their origin. What it can do is be retrained. And what retrains it is repeated lived experience of a different pattern.
This is one of the most consistent findings in the attachment literature, and it has neuroscience backing. The classic Cyberball study by Eisenberger, Lieberman, and Williams showed that being excluded in even a trivial computer ball-tossing game activates the same brain regions associated with physical pain, including the dorsal anterior cingulate cortex (Eisenberger, Lieberman, & Williams, 2003). The brain registers exclusion automatically, before any conscious appraisal, and people report measurable decreases in self-esteem, control, and meaning even from a thirty-second computer-generated snub. These responses do not go away because the person knows the game is rigged. If you have not yet read our earlier post on why therapy clients get stuck, it pairs naturally with this section. The two together describe both the mechanism and the felt clinical experience.
In our conversation, Levine described the clinical implication this way. A client walks out of session and into thousands of social interactions before the next one. Most of those interactions are at minimum mildly disconnecting, and many actively reinforce the client’s existing working model. The session itself, however well conducted, is one fifty-minute counterweight to a week’s worth of evidence in the opposite direction. This is why the lived experience of being seen, included, and consistently shown up for matters more than the reading about it. And it is why the question “what does my client need outside this room?” is just as clinically important as anything we ask inside it.
If you have been sitting with a client whose insight has been ahead of their behavior for months, this is the gap to name explicitly with them. It is also the moment when the next clinical step often is not more therapy. Sometimes the most respectful thing we can do is help a client see that what they need is structured between-session work, the kind that looks more like coaching than processing. Our post on what to do when a client says therapy isn’t working walks through how to have that conversation cleanly. It is one of the most common referral conversations our team has, and clients almost always feel relieved by it.
How do therapists use the therapy relationship to help clients build more secure attachment?
In attachment-based therapy, the therapy relationship is not just the container for the work. It is the work, and it is also the model the client uses to learn what a secure relationship feels like in their nervous system. The therapist’s job is to be reliably present, to repair ruptures cleanly, and to help the client transfer that experience into their actual relationships outside the room.
The empirical case for this is strong. A meta-analysis of adult attachment as a predictor and moderator of psychotherapy outcome found that adult attachment style consistently moderates therapy effectiveness, and that securely attached clinicians are more empathic, repair alliance ruptures more skillfully, and intervene more effectively than insecurely attached clinicians (Levy, Kivity, Johnson, & Gooch, 2018). The therapist’s own attachment patterns, in other words, are doing real work in the therapy whether or not they are being explicitly tracked. Dr. Dan Siegel’s Patterns of Developmental Pathways framework offers a parallel lens for thinking about how personality and attachment intersect inside the therapeutic relationship. It pairs naturally with what Levine teaches.
Levine’s specific contribution is the framework he calls Secure Priming Therapy, structured as a sixteen-session course that integrates the therapy relationship with explicit teaching about how the social brain works. The early sessions help the client understand that attachment patterns are working models rather than fixed traits. The middle sessions teach the client to recognize what Levine calls CARP: Consistent, Available, Responsive, Reliable, and Predictable. The later sessions help the client restructure their actual social environment around those qualities. What is striking clinically is how much of the change happens in what Levine calls SIMIs, or seemingly insignificant minor interactions. The brain does not need a dramatic corrective experience to start updating a working model. It needs many small, repeated, congruent ones.
If this framework lands for you, the next question is what your own attachment patterns are doing in the room with your clients. That is one of the most underdiscussed dimensions of clinical practice, and it tends to be where supervision goes when supervision is working well. Our post on how being a therapist changes you takes the self-of-therapist piece seriously, including the part where our own patterns get activated by client patterns we recognize.
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Join the Collective →What are the most effective attachment-based therapy interventions for anxious and avoidant clients?
The most effective interventions for anxiously and avoidantly attached clients work by giving the client a different experience of safety, not by giving them more insight about why they are not safe. For anxious clients, this means helping them recognize and recruit secure-mode relationships and right-size the relationships that are not. For avoidant clients, it means helping them recognize how their self-sufficiency is unintentionally producing the very neediness in others that they resent.
Levine teaches anxious clients a specific intervention he calls a CARP intervention. The script is essentially this: “I just learned this thing about how my brain works. I really want to be more Consistent, Available, and Responsive in my relationships, and I am looking for the same thing in the people closest to me.” It is an invitation rather than a confrontation. People who can show up that way generally will. People who cannot, and here is the part that matters, get reprioritized rather than abandoned.
The companion technique Levine teaches is what he calls Wall Tennis With Love, where the anxious client maintains warm responsiveness when others reach out, but stops being the one who keeps initiating with people whose attachment style is not a match. The result is that the anxious client’s attachment system stops being constantly activated by relationships that cannot meet it, and the energy redistributes toward relationships that can. If you have been working with a client whose anxious attachment pattern keeps them tethered to people who consistently disappear on them, you have probably also seen the inverse problem of clients ghosting therapy at exactly the moment things start to work. Both patterns trace back to the same nervous-system architecture.
For avoidant clients, the intervention starts in a different place. Levine identifies three pitfalls that avoidant clients fall into without realizing it. The first one is the mismatch between how an avoidant person handles their own distress, which is to handle it alone, push through, and take care of it, and how they unconsciously expect others to handle theirs. When a partner or friend comes to them in distress, the avoidant’s instinct is to ask why this person cannot just take care of it themselves. That response, however reasonable it feels internally, is experienced by the other person as exclusion. And the brain reads exclusion as pain.
This is where the Strange Situation parallel that Levine uses in session lands so clearly with avoidant clients. He shows them the classic attachment research where a toddler whose caregiver leaves the room reacts with full-body distress, drops everything, and runs to the door. He then helps the avoidant client see that when they go cold during a partner’s distress, they are functioning as the caregiver leaving the room. The other person’s apparent neediness is not a personality flaw. It is the predictable nervous-system response to exclusion that Eisenberger’s research has documented.
These are exactly the patterns our coaches at Growing Self work with every day. Most of the clients who come to us for relationship coaching have already done the insight work in therapy. What they are looking for, often without naming it, is the restructuring work between sessions: how to actually do this differently with the actual person on Tuesday at 9pm. Working with someone who knows your patterns and can help you debrief and recalibrate is a different intervention from talking about it once a week. We do free initial consultations exactly for clients who are ready for that step, and we are a good referral when your client is ready.
How do therapists help adults build more secure attachment without reliving the past?
You do not have to take a client back through their childhood to help them build secure attachment as an adult. Levine’s research and his clinical model demonstrate that adult attachment plasticity is real, and that what changes adult attachment patterns is the present-moment experience of safety, not the reprocessing of past wounds. This is what Mikulincer and Shaver have demonstrated through more than thirty studies on contextual security priming.
Mikulincer and Shaver’s broaden-and-build research on attachment security is unambiguous on this point. Contextually boosting a person’s sense of attachment security has measurable, immediate effects on emotion regulation, prosocial behavior, and psychological functioning, and repeated security priming produces cumulative effects over time (Mikulincer & Shaver, 2020). The mechanism is not insight. It is repeated lived experience of being safely connected.
This reframes what we are trying to do clinically. The job is not necessarily to help a client understand why they are insecure. The job is to create the conditions, inside the therapy relationship and outside it, for the client to have repeated experiences of secure connection. Sometimes that requires processing the original wound. Often it does not. What it always requires is structured attention to the present.
This is one of the most freeing reframes I have encountered as a clinician, and it is the one I take into my own work most consistently. If you want to keep developing your thinking on attachment-based work, the place to be careful is the gap between learning a new framework and applying it competently with real clients. We have written before about the risks of therapists adding coaching skills without proper certification, and the same caution applies to attachment-based interventions. Knowing the framework is not the same as knowing how to use it ethically with a real client. That is what our certification work exists to address.
Why reading this article probably isn’t enough
I want to be honest with you about something. The frameworks I just walked you through are real and they work. People use them. Lives change because of them. But I would be doing you a disservice if I let you close this article thinking that reading it was the work.
Here is what almost always happens. You read an article like this one. Something clicks. You feel a little hopeful. You make a mental note to bring some of these ideas into your next session with your stuck client. Then the session happens, and you are tired, and the client is in their pattern, and you find yourself doing roughly what you have always done, wondering why nothing changed.
The reason is simple. You are not unmotivated, and you are not undertrained. You are trying to integrate a new clinical framework, by yourself, into a caseload of people whose patterns are most active in the very moments you would be applying the new framework. That is the hardest possible time to try new behavior. It is almost impossible to do alone. There is also a real ethical dimension to integrating coaching work into clinical practice, and it is worth thinking about where the coaching ethics line sits for therapists before you start doing this work in earnest with your clients.
What works is doing this kind of integration in community with other clinicians who are working on the same thing, and with structured support that helps you recalibrate between sessions. That is what the free Therapist Growth Collective and our coaching certification work at Growing Self exist for. Not lectures. Not slide decks. A real, ongoing professional context in which to do this kind of integration work with colleagues who get it. If something in this article landed somewhere specific for you, that is the signal to talk to someone. We do free info sessions for the certification, and the Collective is free to join. No pressure. Just a real conversation about whether what we do here would help you do what you are already trying to do.
Most of what made this conversation with Amir matter to me clinically came down to a single reframe. We are not in the business of helping clients understand why they are insecure. We are in the business of creating the conditions for them to access a mode they already have capacity for. Once you take that frame seriously, almost everything about what you are trying to do in session, and what you send the client home to practice, changes.
Thank you for reading. I will see you in the next episode.
Xoxo,
Dr. Lisa Marie Bobby
P.S. The full conversation with Amir, including all the resources he mentioned and the Attachment Topography Calculator he developed at Columbia, is available right above this article in the Megaphone player. The Therapist Growth Collective is the place to keep this conversation going with colleagues. And if you are thinking about adding structured coaching skills to your clinical work, request the program guide and we will set up a real conversation about whether it is a fit for where you are.
About this episode’s experts
Dr. Amir Levine
Adult and child psychiatrist trained at New York Presbyterian/Columbia University, where he ranked first in his class three consecutive years. Molecular neuroscientist who trained under Nobel laureate Dr. Eric Kandel. Director of the SecureLab at Columbia. Co-author of Attached: The New Science of Adult Attachment (3M+ copies, 42 languages) and the new follow-up Secure: The Revolutionary Guide to Creating a Secure Life (Avery / Penguin Random House, 2026). Supervises and trains therapists internationally in attachment neuroscience-based treatment.
Dr. Lisa Marie Bobby
Licensed psychologist, marriage and family therapist, and Board Certified Coach. Founder of Growing Self Counseling & Coaching. Host of the Love, Happiness & Success podcast (15M+ downloads). 25+ years of clinical practice. Creator of the Growing Self Institute, where she trains licensed mental health professionals in evidence-based coaching psychology.
Resources Dr. Lisa talked about in this episode
Sources cited in this episode
- Eisenberger, N. I., Lieberman, M. D., & Williams, K. D. (2003). Does rejection hurt? An fMRI study of social exclusion. Science, 302(5643), 290–292. https://doi.org/10.1126/science.1089134
- Levy, K. N., Kivity, Y., Johnson, B. N., & Gooch, C. V. (2018). Adult attachment as a predictor and moderator of psychotherapy outcome: A meta-analysis. Journal of Clinical Psychology, 74(11), 1996–2013. https://doi.org/10.1002/jclp.22685
- Mikulincer, M., & Shaver, P. R. (2020). Broaden-and-build effects of contextually boosting the sense of attachment security in adulthood. Current Directions in Psychological Science, 29(1), 22–26. https://doi.org/10.1177/0963721419885997
