Le trouble de stress post-traumatique (TSPT), caractérisé par ses symptômes complexes issus de l’interaction entre un individu, un traumatisme et un contexte particulier, représente un défi majeur de santé publique. Il perturbe profondément le fonctionnement psychologique, émotionnel et relationnel. La théorie de l’attachement de Bowlby et Ainsworth offre un cadre conceptuel précieux pour appréhender l’impact des traumatismes sur les relations interpersonnelles et les modèles d’attachement.

Cet article explore comment la qualité de l’attachement influence l’apparition ou l’aggravation des symptômes post-traumatiques, et en quoi les dynamiques relationnelles inhérentes au trouble affectent l’alliance thérapeutique, à travers le prisme de la théorie de l’attachement.

Cette revue de littérature s’appuie sur des travaux issus de la psychopathologie développementale, portant sur l’attachement, le TSPT et l’alliance thérapeutique. Les sources, choisies pour leur pertinence clinique et théorique, proviennent d’ouvrages de référence et d’articles spécialisés.

Le TSPT peut être compris comme une désorganisation des modèles internes d’attachement, résultant de l’activation simultanée et prolongée du système d’alarme et du système d’attachement. Les représentations de soi et des autres sont perturbées, amenant à une alternance entre hyperactivation et inhibition des comportements d’attachement. Les styles préoccupé, détaché et craintif sont associés à des symptômes plus sévères. Plus particulièrement, les événements traumatiques intenses, prolongés ou interpersonnels peuvent aggraver cette insécurité ou altérer un attachement initialement sécure.

Une approche thérapeutique éclairée par la théorie de l’attachement permet de mieux appréhender les dynamiques relationnelles à l’œuvre dans le TSPT, et de construire une alliance de travail en tant que base de sécurité autour de laquelle s’organise le processus thérapeutique, soutenant la résilience et la régulation émotionnelle des patients traumatisés.

Post-traumatic stress disorder (PTSD), characterized by its complex symptoms arising from the interaction between an individual, a traumatic event and a particular context, represents a major public health challenge. It leads to a wide range of symptoms that profoundly affect psychological, emotional, and relational functioning. Through the work of John Bowlby and Mary Ainsworth, attachment theory provides a valuable lens for understanding the impact of traumatic events on interpersonal relationships and attachment patterns.

This article explores how attachment styles influence the onset or worsening of post-traumatic symptoms, and how the relational dynamics inherent to the disorder affect the therapeutic alliance, through the lens of attachment theory.

This literature review is based on research from developmental psychopathology, focusing on attachment, PTSD, and the therapeutic alliance. Sources were selected for their clinical and theoretical relevance, including reference books and specialized articles.

PTSD can be understood as a disorganization of attachment internal working models, resulting from the simultaneous and prolonged activation of both the alarm and attachment systems. This disorganization disrupts representations of the self and others, leading to an alternation between hyperactivation and inhibition of attachment-related behaviors. Preoccupied, dismissing, and fearful attachment styles, are associated with more severe post-traumatic symptoms. The literature highlights that intense, prolonged, or interpersonal trauma, can exacerbate attachment insecurity or even disrupt a previously secure attachment style. Furthermore, chronic PTSD may itself modify attachment patterns over time. A person with a secure attachment style may develop insecurity after a traumatic experience, while someone already insecure may see their negative internal representations of self and others be reinforced. These findings support the hypothesis that the clinical manifestations of PTSD reflect, at least in part, a breakdown in attachment patterns and emotional regulation mechanisms.

An attachment therapeutic approach offers valuable insight into the relational impasses that may arise during PTSD treatment. These difficulties are particularly significant in patients with previous insecure or disorganized attachment styles, for whom relational trust and help-seeking behaviors may be impaired. The therapeutic relationship, as an attachment-relevant situation, becomes a key space for restoring emotional regulation and providing corrective relational experiences. Focusing on relational dynamics contributes to building a working alliance that functions as a secure base around which the therapeutic process can be structured. This alliance supports emotional regulation through safety, while also fostering the development of resilience in traumatized patients. It enables patients to explore their distress and gradually integrate the traumatic experience. Particular attention must be paid to the therapist's availability, predictability, and awareness of their own attachment style, in order to better identify and respond to attachment-related behaviors that may interfere with the therapeutic process. From this perspective, the therapeutic alliance should be built on mutual trust, shared goals and emotional attunement. The therapeutic relationship thus becomes a space where internal working models can be reorganized, leading to improved emotional regulation and a reduction in PTSD symptoms. This highlights the essential role of intersubjectivity in psychiatric practice and ultimately provides not only a theoretical insight into PTSD treatment, but also for the general psychiatric care.