Treatment needs to allow addicted clients to “earn Attachment”

In this article (1) we look at attachment in relation to affect regulation and interpersonal functioning among substance use disorders inpatients.  The conclusions of this study give some therapeutic insight into how these individuals with insecure attachment even in adulthood need to be facilitated to learn and earn attachment in group therapy settings.

The objective of the present study was to investigate potential associations between attachment, Negative Mood Regulation (NMR) expectancies, fear of
intimacy and self-differentiation in substance abusers. The Revised Adult Attachment Scale (RAAS), the NMR Expectancies Scale, the Fear of Intimacy Sale and the Differentiation of Self Inventory were administered to a sample of 100 substance use disorder inpatients.

Attachment is associated with the expression and regulation of emotion (Cassidy, 1994; Mikulincer & Shaver, 2007; Thompson, 1999). Early attachment theory postulates that bonding with a significant caregiver is essential for the development of internal working models for communication, regulation of emotions and interpersonal behaviour (Bowlby, 1973; Sroufe & Fleeson, 1986). These early attachment experiences are associated with adult attachment styles.

Adult attachment styles are relatively stable and influence attitudes, emotions, affect regulation and behavioural strategies in relationships (Gillath & Shaver, 2007; Mikulincer & Shaver, 2007; Shaver & Mikulincer, 2002). Empirical evidence has indicated associations between insecure adult
attachment, fear of intimacy and emotion regulation difficulties (Bekker, Bachrach, & Croon, 2007; Hazan & Shaver, 1987) and between secure adult attachment and a higher capacity for intimacy, emotional awareness and empathy (Feeney, 1996; Laible, 2007).

Substance abuse has been proposed to be a consequence of emotion regulation difficulties (Magai, 1999; Taylor, Bagby, & Parker, 1997) with individuals using alcohol/drugs to avoid intimacy or rejection, to ease pain,
anger and ambivalence and possibly establish a “secure base” (Hofler & Kooyman, 1996).

Moreover, addiction has been proposed to be an attachment disorder (Flores, 2001, 2004) and research suggests that insecure attachment is associated with alcohol consumption, harmful drinking patterns and substance use disorders (Cooper, Shaver, & Collins, 1998; Finzi-Dottan, Cohen,
Iwaniec, Sapir, & Weizman, 2003; McNally, Palfai, Levine, & Moore, 2003; Thorberg & Lyvers, 2006; Vungkhanching, Sher, Jackson, & Parra, 2004).

Negative mood regulation (NMR) expectancies are beliefs regarding a person’s ability to terminate or alleviate a negative mood state (Catanzaro & Mearns, 1990). High NMR presumably  reflects the ability to cope successfully with bad moods, whereas low NMR may lead to maladaptive or less efficacious ways of coping (Kassel, Bornovalova, & Mehta, 2007). Evidence suggests that low NMR expectancies predict avoidant coping, problem drinking (Catanzaro & Greenwood, 1994; Catanzaro & Laurent, 2004; Davis, Andresen, Trosko, Massman, & Lovejoy, 2005; Flett, Blankstein, & Obertynski, 1996).

Individuals with insecure attachment orientations report less confidence in their ability to regulate moods compared to secure individuals (Creasey,
Kershaw, & Boston, 1999). Creasy and Ladd (2004) also found that the relationship between NMR and the ability to resolve conflict with a partner was mediated by attachment,  highlighting the importance of attachment as a mechanism of the ability to cope with negative feelings and resolve conflict in close relationships.

Interestingly, a study by Moller et al. (2002) found that individuals with “earned attachment security”, described as the ability to maintain high levels of interpersonal functioning in spite of growing up in a problematic childhood environment.

Some have also argued that fear of intimacy (FIS) is associated with mental health issues and substance use problems (Descutner & Thelen, 1991).  Descutner and Thelen defined FIS as “the inhibited capacity of an individual, because of anxiety, to exchange thoughts and feelings of personal significance with another individual who is highly valued” (p.219). FIS research to date
has largely reported significant associations with loneliness, lack of self-disclosure, low social interaction and poor relationship quality (Descutner & Thelen, 1991; Doi & Thelen, 1993).

Differentiation of self is defined as the degree to which an individual is able to balance emotional and intellectual functioning, intimacy and autonomy in relationships (Bowen, 1976, 1978).  Individuals with lower self-differentiation experience higher levels of chronic anxiety, emotion regulation difficulties, mood disturbances and substance abuse.

A study in a community sample reported associations between insecure attachment and the four dimensions of the self-differentiation measure: Emotional reactivity (ER), Emotional cut-off (EC), I position (IP) and Fusion with others (FO).

Previous studies among substance use disorders have reported higher levels of mood regulation and interpersonal difficulties compared to controls (Lyvers, Thorberg, Dobie, Huang, & Reginald, 2008; Thorberg & Lyvers,
2005, 2006) highlighting the importance of  research on attachment in relation to NMR and self-differentiation.

Findings of this study (1) are as follows-

Addicts in the present study had significantly higher levels of insecure attachment compared to student and community samples.

There was evidence for less confidence in mood regulation abilities among substance abusers. In addition, anxious attachment predicted 7.7% of the variance in NMR expectancies,  suggesting that anxious attachment is associated with lesser abilities to regulate one’s negative moods. This is in accordance with other research evidence (Bekker et al., 2007; Collins, 1996; Simpson, Rholes, & Phillips, 1996) and attachment theory (Main, 1996; Mikulincer & Shaver, 2007) suggesting that insecurely attached individuals tend to show poor affect regulation.

This  study also found higher fear of intimacy scores among the substance use
disorder patients compared to a student sample.   Furthermore, attachment was also a strong predictor of FIS. Results suggest that adult attachment is related to difficulties in intimacy and interpersonal functioning, in accordance with previous evidence that reported a significant association between insecure attachment and relationship problems as well as lower levels of trust, interdependence and commitment (Cyranowski et al., 2002; Simpson, 1990).
This is in line with attachment theory proposing that individuals with a fearful attachment style long for intimacy, but avoid close relationships for fear of rejection (Bartholomew & Horowitz, 1991).
Thus, some substance abusers may self-medicate to reduce their fear of intimacy (see Khantzian, 2003) or help them cope with intimacy in close relationships, at least for a short period of time.



Attachment dimension scores from the current study explained significant variance in self-differentiation. Given the present findings we speculate that
attachment dimensions may be associated with the development of self-differentiation.

Anxious attachment scores significantly predicted emotional reactivity (ER), those with  anxious attachment  are more likely to be more emotionally reactive, having difficulties with emotion regulation, and maladjustment in those with substance dependence (Skowron & Friedlander, 1998)

The predictive utility of attachment dimensions was also shown for Emotional cut-off (EC)  in line with previous research suggesting a link between
attachment and EC (Skowron & Dendy, 2004) in those with substance problems and implies that attachment dimensions are related to traits of emotional aloofness, anxiety, isolation from others and exaggerated independence (Nichols & Schwartz, 1998; Skowron & Friedlander, 1998). EC may be associated with, or a consequence of alexithymia, a personality trait associated with difficulties in identifying and describing feelings.

In addition, attachment was examined in relation to I position (IP), the present data support the autonomous role of the Close attachment dimension in influencing a personality characteristic such as IP. IP refers to an ability to maintain a strong sense of self, have flexible boundaries and remain calm under stress (Skowron & Friedlander, 1998), and secure attachment is associated with being comfortable with closeness, having high levels of empathy and emotional insight (Laible, 2007; Lyvers et al., 2008).

The findings of the current investigation highlight important implications for clinical practice. One potential goal of treatment could be to establish “earned attachment security” in the context of group psychotherapy, where individuals can rewrite historical working models of insecure childhood attachment and adult attachment security may be earned (McCarthy et al., 2002). Thus, attachment patterns could be assessed pre-treatment and then targeted during treatment, with a goal of establishing security based emotion regulation strategies (DeRick & Vanheule, 2007; Mikulincer, Shaver, & Pereg, 2003) as attachment information reflects rules and strategies associated with emotions (Fouladi, McCarthy, & Moller, 2002).

Given that addicts report using alcohol and drugs to regulate negative moods, perhaps “earned attachment security” through therapeutic efforts and an increased confidence in mood regulation abilities may lead to decreased levels of negative affect that could potentially decrease the use of substances as a
mood regulator.


Thorberg, F. A., & Lyvers, M. (2009). Attachment in relation to affect regulation and interpersonal functioning among substance use disorder in patients.Addiction Research & Theory, 18(4), 464-478.




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