Adult Attachment Interview (AAI): History, Applications and Impact

The Adult Attachment Interview (AAI) aims to assess changes attachment patterns in adulthood. This article explains the AAI assessment process and techniques in depth.

According to previous research, 55-65% of the general population are securely attached¹. However, clinicians are typically more familiar with the other 35-45% – those with an insecure attachment style.

People tend to come to The Attachment Project for a variety of reasons. Often, it’s due to relationship difficulties. However, others may come because of low self-esteem or mental health conditions that stem from their past experiences.

Part and parcel of understanding clients is getting to know their attachment style. But unfortunately, identifying this isn’t always straightforward. What’s more, with the mass of test options out there, it’s difficult to find a reliable method that you trust enough to use in practice.

Here’s where the Adult Attachment Interview (AAI) enters the equation. The AAI is a semi-structured interview developed by trained psychologists to help mental health professionals identify their clients’ attachment styles. It’s highly accurate, making it a valuable clinical tool that you can trust.

But what is the AAI? And how can it be applied in clinical practice? In this article, we will answer all of your questions on the Adult Attachment Interview, including:

• What is the Adult Attachment Interview?
• What is the process of the AAI?
• How does attachment theory apply to the AAI?
• What is involved in the training and application of the AAI?
• What are some of the questions included in the AAI?
• What are the future and challenges of the AAI?

Introduction to Adult Attachment Interview

The Adult Attachment Interview (AAI) is a semi-structured interview aimed at understanding a person’s childhood experiences with their main caregivers to identify their attachment style. It has 20 core questions, but more questions may be asked depending on the direction it takes – this is what makes it “semi-structured”. It probes into several areas of childhood relationships, including:

• How close the interviewee felt to their parents
• Whether the interviewee ever felt rejected as a child
• If they remember their caregivers ever being threatening
• Their take on why their caregivers behaved in certain ways
• How the interviewee’s childhood experiences impact them in adulthood
• What major losses they experienced in childhood, if any

The AAI was first published by American psychologists Mary Main, Carol George, and Nancy Kaplan in 1985, but researchers have continued to develop it over the years². In 2002, Main and colleagues developed a scoring system for the AAI, which helps clinicians match a person’s past experiences with their current attachment style. There are five categories in the classification system³:

• Secure (also called Free or Autonomous): Securely attached people have a balanced and coherent recollection of childhood experiences, and value their attachments to others.
• Dismissing: Dismissively attached people may either idealize or devalue their childhood attachments.
• Preoccupied (also called Entangled): People who classify as preoccupied tend to hold on to anger or concern with their childhood attachments.
• Unresolved (also called Disorganized): This category is assigned alongside one of the former 3 categories. People in the Unresolved category have a history of significant loss or abuse in childhood and find it difficult to produce a coherent narrative.
• Cannot Classify: Individuals who don’t fall into categories 1 – 4 are placed in the “Cannot Classify” category. This means they show no single predominant attachment style and a very incoherent approach to their childhood memories.

The AAI is now a widely used tool among clinicians in helping to identify patients’ attachment styles. This aids therapeutic work in more ways than one. But more on that soon. First, what is the process involved in the AAI?

Process of the AAI

The AAI process typically starts when a person is experiencing relationship difficulties in adulthood. Perhaps they’re struggling to choose a healthy partner, can’t seem to build long-lasting friendships, or have chaotic family relationships. Whatever the reason, they will likely seek help from a trained mental health professional such as a psychiatrist or psychotherapist.

Training for the AAI is a rigorous process, and the scoring manual is only available to those who are on official training courses. If you’re interested in undergoing the Adult Attachment Interview process, make sure you choose a clinician with proper accreditation and training in the AAI specifically.

The AAI can be conducted at any useful point in time, possibly in the introductory assessment session or a little later in the process when trust has begun to build between you and the clinician.

The interview itself typically takes around 60-90 minutes, and is audio recorded. The audio recording will then be transcribed word for word, which can take around 10 hours, and the transcription will then be analyzed under the AAI scoring and classification system – this can take around 4 more hours⁴. While your clinician may be able to reflect on your experience of the AAI with you afterwards, it takes at least several days for the classification process to be complete.

The scoring system for the AAI includes a number of scales, such as⁵:

• Coherence of Transcript: If the interviewee’s account of their past experiences is coherent and all adds up, this would give them a high rating on the coherence of transcript scale.
• Idealization of Parent: Interviewees who omit their negative early experiences and speak abnormally highly of their caregivers, as if they can see no wrong in their actions, demonstrate idealization of their caregivers.
• Insistence on Lack of Recall: If the interviewee claims not to remember much of their childhood or their relationship with their caregivers, this indicates a lack of recall.
• Involving or Occupying Anger: The level of anger the interviewee shows when speaking about their caregivers.
• Passivity or Vagueness of Discourse: Interviewees who can’t stay on topic or explain their past experiences in an emotionless or vague way would score highly on the passivity or vagueness of discourse scale.

High ratings on Coherence of Transcript would contribute to a Secure classification. Meanwhile, high ratings on the Idealization of Parent and Insistence on Lack of Recall scales would suggest a Dismissing attachment style. Someone scoring high on Involving or Occupying Anger and Passivity or Vagueness of Discourse is more likely to be classified as Preoccupied. And if they didn’t fall into any category, the clinician would mark them as “Cannot Classify.”

Once the person has received a classification, both they and the clinician can use this information to develop a plan for therapeutic work. The clinician’s role, after this point, is to combine therapeutic knowledge of research with the information they have about their client to guide them to the best possible therapeutic approach.

To do this, they need to understand how attachment theory informed the AAI.

Application of Attachment Theory in the AAI

Attachment theory, a set of ideas developed by British psychiatrist and psychoanalyst John Bowlby in the 1960s, forms the foundation of the Adult Attachment Interview. This theory proposes that our early relationships shape how we think, feel, and behave in adulthood and lays the groundwork for all future research into attachment relationships.

From Bowlby’s research, Mary Ainsworth developed her Strange Situation Procedure, a study that involved recording children’s reactions in certain conditions. These conditions were as follows:

1. Being in a room with their mother and an experimenter.
2. Mother and baby are alone in the room together.
3. A stranger enters the room with the mother and baby.
4. The mother leaves the baby alone with the stranger.
5. The mother returns and the stranger leaves.
6. The baby is left on their own in the room.
7. The stranger returns, so only the stranger and the baby are in the room alone.
8. Mother returns, and the stranger leaves.

Ainsworth assessed how each child responded to these conditions and created three attachment styles based on their behaviors:

• Secure (Type B)
• Insecure avoidant (Type A)
• Insecure ambivalent/resistant (Type C)

Then, in 1990, the work of Mary Main and Judith Solomon highlighted a new attachment pattern; disorganized attachment. This was intended to be used alongside the existing 3 attachment styles, much like the Unresolved AAI categorization, rather than as a fourth attachment type.

Much of the early attachment research focused on understanding attachment styles in children. However, as the interest in attachment research grew, Mary Main, Carol George, and Nancy Kaplan turned their attention to identifying attachment styles in adults. They used the work of Bowlby and Ainsworth to inform their research, and in doing so, came up with the Adult Attachment Interview.

Training to Use the Adult Attachment Interview

There are various courses available if clinicians want to train to use the Adult Attachment Interview effectively within their practice.

AAI training involves a short course, usually taking 3-14 days to complete. During this training, mental health professionals have the chance to learn new ways to understand the impact of insecure early relationships. They will also learn how to identify distortions in an adult’s thoughts, feelings, and behaviors relating to an insecure attachment style.

Passing an AAI training course is very difficult because clinicians have to prove that they will rate AAIs with a very high standard of accuracy. This keeps the AAI in good standing as a psychometric tool.

But why would you choose to learn how to run an AAI? What are the possible applications in clinical practice?

Clinical Applications of the Adult Attachment Interview

The Adult Attachment Interview has proven to be a powerful clinical tool over the years, with more than one valuable clinical application. Here is a collection of five of the main clinical applications of the AAI:

1. Helps clinicians set an agenda

The AAI helps clinicians set the agenda of any therapeutic work, as it can help clients link their current troubles and ways of thinking, behaving, and feeling to their childhood experiences. This shared understanding sets the foundation for what the therapeutic work will focus on and how the clinician can help.

2. Strengthens the therapeutic alliance in therapy

When the clinician shows an interest and asks questions about the client’s early life, this begins to build trust. The client sees that someone is on their side who wants to understand and listen to them, which strengthens the therapeutic bond.

3. Reveals past traumas and losses

The questions within the AAI pay particular attention to any traumas and losses that the patient experienced early in life. As the AAI includes questions that most people have never been asked before, the interview offers an opportunity for clients to learn more about their traumas and losses and for clinicians to paint a more detailed picture of their clients.

4. Uncovers the interviewee’s defenses

Our early experiences shape how we think, feel, and behave in adulthood. When our early experiences are secure, we learn to navigate the world in healthy ways. But when we grow up in unhealthy or chaotic environments, we develop defenses that we use to protect ourselves. As we get older, however, these defenses stop protecting us and instead begin to negatively impact our lives.

For example, those within the Dismissing classification rely on avoiding closeness and intimacy as a defense. This defense started because their caregivers were rejecting or unreliable, which meant that the only way to protect themselves was to be independent and keep their distance. However, in adulthood, this defense prevents them from forming strong, healthy relationships.

The AAI can help clinicians identify the interviewee’s defenses, which can help the clinician decide on the best course of action to support their client.

5. Allows clinicians to identify a patient’s progress after treatment

Mental health professionals can assess their patients before, during, and then again after a course of treatment to see if there are any changes in their attachment presentation. This can help them to track the progress of the work. Researchers can also use the AAI to compare the effectiveness of different forms of therapy.

Researchers Levy and colleagues tried this in a randomized, controlled treatment trial, where 90 outpatients with borderline personality disorder were given one of three forms of therapy: transference-focused psychotherapy, psychodynamic supportive psychotherapy, or dialectical behavior therapy⁶. One year into treatment, they found that the frequency of secure attachment classification was 5 – 15% higher for patients but only those treated with transference-focused psychotherapy.

Common AAI Questions

The 20+ questions within the AAI cover various aspects of childhood, helping the clinician paint a comprehensive picture of the interviewee’s early life. Some simplified versions of the questions a clinician would ask during the AAI are:

• What five adjectives would you use to describe your relationship with your mother/father as far back into childhood as you remember?
• Which parent do you feel closest to?
• When you were upset as a child, what would you do?
• Did you ever feel rejected as a child?
• Did you experience any big losses as a young child?
• How do you think your childhood experiences with your parents have affected your personality?

Please note that this is not a complete list of the questions but a quick snapshot of some of the main points covered.

The AAI protocol is available to the public, but it’s best not to prepare your answers if you plan to undergo the interview.

Future and Challenges of the Adult Attachment Interview

The AAI has proven to be highly effective in classifying people’s attachment styles, but like all assessment measures, it comes with drawbacks. A number of factors may reduce the accuracy of the AAI, including:

• Language barriers: Translating psychometric measures into other languages isn’t a simple process, as meaning can easily be lost or distorted. If English isn’t your first language and the AAI isn’t available in your native language, misunderstandings may impact your results.
• Classification systems: We have discussed Main and colleagues’ Berkeley system, but another classification system exists (Dynamic-Maturational Model, or DMM) – some studies have found differences in attachment results when different systems are used to classify the same interviews³.
• Bias: Although AAI interviewers must pass rigorous training, any individual or organization can be subject to conscious or unconscious bias which may impact the interviewing and coding process.

The AAI is undoubtedly a valuable tool to have in your clinical toolbox. However, it’s important to bear these points, and any other potential challenges, in mind before using the AAI within your practice.

References

1. Mickelson KD, Kessler RC, Shaver PR. Adult attachment in a nationally representative sample. Journal of personality and social psychology. 1997 Nov;73(5):1092.
2. Talia A, Miller-Bottome M, Wyner R, Lilliengren P, Bate J. Patients’ Adult Attachment Interview classification and their experience of the therapeutic relationship: are they associated?. Research in Psychotherapy: Psychopathology, Process, and Outcome. 2019 Jul 30;22(2):361.
3. Baldoni F, Minghetti M, Craparo G, Facondini E, Cena L, Schimmenti A. Comparing Main, Goldwyn, and Hesse (Berkeley) and Crittenden (DMM) coding systems for classifying Adult Attachment Interview transcripts: an empirical report. Attachment & human development. 2018 Jul 4;20(4):423-38.
4. Bakermans-Kranenburg MJ, van IJzendoorn MH. The first 10,000 Adult Attachment Interviews: Distributions of adult attachment representations in clinical and non-clinical groups. Attachment & human development. 2009 May 1;11(3):223-63.
5. Lorito L, Scrima FA. The content validity of the adult attachment interview: An empirical investigation using text analysis. TPM-Testing, Psychom Methodol Appl Psychol. 2011;18(4):243-55.
6. Levy KN, Meehan KB, Kelly KM, Reynoso JS, Weber M, Clarkin JF, Kernberg OF. Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of consulting and clinical psychology. 2006 Dec;74(6):1027.