Influence of Attachment on Addiction Addition and Psychiatry Seminars UCLA Donna Markus, Ph.D.

Influence of Influence of Attachment on Attachment on

Addiction Addiction Addition and Psychiatry SeminarsAddition and Psychiatry Seminars

UCLAUCLA

Donna Markus, Ph.D.Donna Markus, Ph.D.

Attachment TheoryAttachment Theory Framework for understanding how an Framework for understanding how an

individual’s early attachment experiences may individual’s early attachment experiences may influence his or her personality development influence his or her personality development and current functioning.and current functioning.

The protective functions of attachment extend The protective functions of attachment extend beyond biological need for security to an beyond biological need for security to an emotion-based sense of security which is emotion-based sense of security which is fundamental to healthy psychological fundamental to healthy psychological functioning. (Bowlby, 1980; Bischoff, 1975; functioning. (Bowlby, 1980; Bischoff, 1975; Bretherton, 1985; Sroufe & Waters, 1977). Bretherton, 1985; Sroufe & Waters, 1977).

Attachment organization contributes to Attachment organization contributes to healthy or pathological patterns of personality healthy or pathological patterns of personality development.development.

Ainsworth “Strange Ainsworth “Strange Situation”Situation”

Securely attached child welcomed mother upon Securely attached child welcomed mother upon reunion and, if distressed, was readily reunion and, if distressed, was readily comforted. Caregiver used as base of security comforted. Caregiver used as base of security to regulate feelings of distress and anxiety to regulate feelings of distress and anxiety provoked by Strange Situation.provoked by Strange Situation.

Insecurely attached unable to be comforted Insecurely attached unable to be comforted during reunion with heightened ambivalent during reunion with heightened ambivalent expressions of attachment and anger or expressions of attachment and anger or avoidance and detachment.avoidance and detachment. Ambivalent: inconsistent, conflicted and indecisive Ambivalent: inconsistent, conflicted and indecisive

attempts to elicit comfort or support.attempts to elicit comfort or support. Avoidant: did not actively seek support nor utilize Avoidant: did not actively seek support nor utilize

caregiver to regulate and dissipate negative affectcaregiver to regulate and dissipate negative affect

Working ModelsWorking Models

Main, Kaplan and Cassidy (1985) suggested Main, Kaplan and Cassidy (1985) suggested that individual differences in attachment that individual differences in attachment styles can be viewed as “differences in the styles can be viewed as “differences in the mental representation of the self in relation mental representation of the self in relation to attachment [and] the secure versus to attachment [and] the secure versus various types of insecure attachment various types of insecure attachment organizations can best be understood as organizations can best be understood as terms referring to particular types of internal terms referring to particular types of internal working models of relationships, models that working models of relationships, models that direct not only feelings and behavior but also direct not only feelings and behavior but also attention, memory, and cognition”attention, memory, and cognition”

Working models: based on the child’s affective Working models: based on the child’s affective experiences with primary caregiver, attachment becomes experiences with primary caregiver, attachment becomes structuralized as an internal working model representing structuralized as an internal working model representing the self, attachment figure(s) and the external world. the self, attachment figure(s) and the external world. These working models, or internal representations of self These working models, or internal representations of self and others, help children predict what to expect in terms and others, help children predict what to expect in terms of caregiver responsiveness and availability, and how to of caregiver responsiveness and availability, and how to adjust their behavior accordingly.adjust their behavior accordingly.

Thus, children’s early attachment relationships impact Thus, children’s early attachment relationships impact their emerging self-concept (e.g., whether one is worthy their emerging self-concept (e.g., whether one is worthy of care and attention) and developing view of the social of care and attention) and developing view of the social world (e.g., caring, responsive). These internal world (e.g., caring, responsive). These internal representations are carried forward into new representations are carried forward into new relationships where they guide expectations, perception relationships where they guide expectations, perception and behavior. and behavior.

Attachment patterns are not immutable. Attachment patterns are not immutable. Development “turns at each and every stage Development “turns at each and every stage of the journey on an interaction between the of the journey on an interaction between the organism as it has developed up to that organism as it has developed up to that moment and the environment in which it then moment and the environment in which it then finds itself” (Bowlby, 1973 p. 364). finds itself” (Bowlby, 1973 p. 364).

As Sroufe, Carlson, Levy and Egeland (1999) As Sroufe, Carlson, Levy and Egeland (1999) note, “Child and context are mutually note, “Child and context are mutually transforming…The individual is the product transforming…The individual is the product of all of his or her experiences, not early of all of his or her experiences, not early experiences alone” (p.2)experiences alone” (p.2)

Internalized model determines individual’s Internalized model determines individual’s style of social interactions and emotional style of social interactions and emotional regulation. Future experiences are regulation. Future experiences are interpreted so that continuity in one’s interpreted so that continuity in one’s sense of self is maintained. All current sense of self is maintained. All current and future relationships will be weighed and future relationships will be weighed against the cumulative representation of against the cumulative representation of one’s experiences, particularly when the one’s experiences, particularly when the individual is distressed. Similarly, individual is distressed. Similarly, behavior will be based on expectations behavior will be based on expectations engendered by those comparisons.engendered by those comparisons.

Consequences of disturbed attachment Consequences of disturbed attachment become more apparent during late become more apparent during late childhood and early adolescence . childhood and early adolescence . Individuals who are insecurely attached Individuals who are insecurely attached are less flexible in dealing with stressors are less flexible in dealing with stressors accompanying these developmental accompanying these developmental periods; working models (internal periods; working models (internal representations of self and others) and representations of self and others) and strategies for regulating distress often strategies for regulating distress often result in maladaptive responses. result in maladaptive responses.

Attachment stylesAttachment styles

Secure attachment associated with a Secure attachment associated with a positive self-concept, self-efficacy, positive self-concept, self-efficacy, healthy interpersonal relations and a healthy interpersonal relations and a sense of well being (Arend, Gove, & sense of well being (Arend, Gove, & Sroufe, 1979; Collins & Read, 1990; Sroufe, 1979; Collins & Read, 1990; Cummings & Cicchetti, 1990; Hazan & Cummings & Cicchetti, 1990; Hazan & Shaver, 1987; Matas, Arend, & Sroufe, Shaver, 1987; Matas, Arend, & Sroufe, 1978; Simpson, 1990; Sroufe, 2000; 1978; Simpson, 1990; Sroufe, 2000; Sroufe, Carlson, Levy, & Egeland, Sroufe, Carlson, Levy, & Egeland, 1999).1999).

Attachment styles Attachment styles (cont’d)(cont’d)

Insecure attachment styles: difficulty with Insecure attachment styles: difficulty with affect management, exhibit maladaptive affect management, exhibit maladaptive coping strategies when confronted with coping strategies when confronted with stressful situations (Kobak & Sceery, 1988; stressful situations (Kobak & Sceery, 1988; Main, 1990; Main, Kaplan, & Cassidy, 1985; Main, 1990; Main, Kaplan, & Cassidy, 1985; Mikulincer, Florian, & Tolmacz, 1990)Mikulincer, Florian, & Tolmacz, 1990)

Related to an array of psychological difficulties Related to an array of psychological difficulties including anxiety, depression, substance abuse including anxiety, depression, substance abuse (e.g., Allen et al, 1996; Bowlby, 1978; Burge et (e.g., Allen et al, 1996; Bowlby, 1978; Burge et all., 1997; Cole-Detke & Kobak, 1996; all., 1997; Cole-Detke & Kobak, 1996; Rosenstein & Horowitz, 1996). Rosenstein & Horowitz, 1996).

Attachment Styles and Affect Attachment Styles and Affect RegulationRegulation

Working models appear to influence an individual’s Working models appear to influence an individual’s affective responses to emotionally distressing situations affective responses to emotionally distressing situations as well as the methods or strategies individuals use for as well as the methods or strategies individuals use for coping with such distress (Kobak & Sceery, 1988; coping with such distress (Kobak & Sceery, 1988; Mikulincer et al., 1990; Sroufe & Waters, 1977). Mikulincer et al., 1990; Sroufe & Waters, 1977).

Cognitive schemata related to attachment experiences Cognitive schemata related to attachment experiences and style influence one’s level of awareness of negative and style influence one’s level of awareness of negative feelings. feelings.

If attachment figure has been responsive and available If attachment figure has been responsive and available to child’s distress signals, distress can be regulated to child’s distress signals, distress can be regulated with strategies that involve active seeking of support with strategies that involve active seeking of support and comfort – able to acknowledge distress, turn to and comfort – able to acknowledge distress, turn to others for support, and able to modulate negative affect others for support, and able to modulate negative affect in a constructive manner.in a constructive manner.

Attachment styles and affect regulation Attachment styles and affect regulation (cont’d)(cont’d)

Insecurely attached individuals Insecurely attached individuals display a propensity to either:display a propensity to either:

exaggerate negative emotions in an exaggerate negative emotions in an attempt to elicit a response figure, orattempt to elicit a response figure, or

Inhibit negative emotions to reduce the Inhibit negative emotions to reduce the anxiety induced by an unresponsive anxiety induced by an unresponsive attachment figure.attachment figure.

Attachment styles and affect regulation Attachment styles and affect regulation (cont’d)(cont’d)

Avoidant attachment styleAvoidant attachment styleModulate negative feelings by restricting Modulate negative feelings by restricting

acknowledgement of distress and being acknowledgement of distress and being “compulsively self-reliant” rather than “compulsively self-reliant” rather than exhibiting behaviors aimed at seeking comfort exhibiting behaviors aimed at seeking comfort and support. This strategy entails a dismissal and support. This strategy entails a dismissal of the importance of attachment relations, an of the importance of attachment relations, an inhibition of the display of negative emotions, inhibition of the display of negative emotions, and an emphasis on autonomyand an emphasis on autonomy

Ambivalent attachment styleAmbivalent attachment styleNegative feelings intensified because they Negative feelings intensified because they

direct attention toward distress in a direct attention toward distress in a hypervigilant manner that functions to inhibit hypervigilant manner that functions to inhibit the development of autonomy and self-the development of autonomy and self-confidence.confidence.

SOCIAL SUPPORTSOCIAL SUPPORT

Since attachment theory is Since attachment theory is concerned with effects of early concerned with effects of early attachment relationships on one’s attachment relationships on one’s emerging view of self, expectations emerging view of self, expectations of others, and capacity for close of others, and capacity for close relationships, it’s not surprising that relationships, it’s not surprising that a link between attachment style or a link between attachment style or organization and social support has organization and social support has been established.been established.

Social Support (cont’d)Social Support (cont’d)

Relationship between social support and positive Relationship between social support and positive outcomes for recovering addicts has been supported outcomes for recovering addicts has been supported by research (e.g., Gordon & Zrull, 1991; Humphrey, by research (e.g., Gordon & Zrull, 1991; Humphrey, Moos & Cohen, 1997; Miller, Ninonuevo, Klamen, Moos & Cohen, 1997; Miller, Ninonuevo, Klamen, Hoffman & Smith, 1997).Hoffman & Smith, 1997).

Difficulties in establishing supportive relationships Difficulties in establishing supportive relationships with which to recover are based on a history of with which to recover are based on a history of unsuccessful interpersonal experiences. Histories of unsuccessful interpersonal experiences. Histories of addicts as well as histories of children raised in addicts as well as histories of children raised in substance abusing households reveal impoverished substance abusing households reveal impoverished social support resources as well as a limited capacity social support resources as well as a limited capacity for these children to utilize such resources (Bays, for these children to utilize such resources (Bays, 1990; Black, 1985, 1988; Black, Bucky, & Wilder-1990; Black, 1985, 1988; Black, Bucky, & Wilder-Padilla, 1986; deCubas & Field, 1993).Padilla, 1986; deCubas & Field, 1993).


Research supports theoretical assumptions Research supports theoretical assumptions regarding the differences in how securely regarding the differences in how securely attached, avoidantly attached and ambivalently attached, avoidantly attached and ambivalently attached individuals view themselves in attached individuals view themselves in relationship with significant others.relationship with significant others.

Likewise, the divergent cognitive schemata Likewise, the divergent cognitive schemata associated with these attachment styles extend associated with these attachment styles extend to differences in these individual’s perception to differences in these individual’s perception and use of social support system (Florian, and use of social support system (Florian, Mikulincer & Bucholtz, 1995; Kobak & Sceery, Mikulincer & Bucholtz, 1995; Kobak & Sceery, 1988; Simpson, Rholes, & Nelligan, 1992)1988; Simpson, Rholes, & Nelligan, 1992)


Support perceived to be available is more Support perceived to be available is more consistently related to outcome measures consistently related to outcome measures than support actually received (Sarason, than support actually received (Sarason, Shearin, Pierce, and Sarason, 1987). As Shearin, Pierce, and Sarason, 1987). As such, social support provides a protective such, social support provides a protective function. Furthermore, as a result of this function. Furthermore, as a result of this belief, individuals feel assured that they belief, individuals feel assured that they can overcome challenges and pursue can overcome challenges and pursue goals through their own effort or with goals through their own effort or with assistance from significant others.assistance from significant others.

Demographics Demographics (N=206)(N=206) GenderGender Male 91 44.2%Male 91 44.2% Female 115 55.8%Female 115 55.8% EthnicityEthnicity Asian 2 1.0%Asian 2 1.0% African-American 25 12.1%African-American 25 12.1% Caucasian 128 62.1%Caucasian 128 62.1% Hispanic 32 15.5%Hispanic 32 15.5% Native American 3 4.5%Native American 3 4.5% Multi- or Bi-Racial 15 7.3%Multi- or Bi-Racial 15 7.3% Other 1 .5%Other 1 .5% AgeAge Mean 45.5 SD 10.26Mean 45.5 SD 10.26

Number of Years Abstinent

N %

1-4 years 52 25.2%

5-9 years 51 24.8%

10-14 years 32 15.5%

15-19 years 41 19.9%

20-24 years 18 8.7%

>25 years 12 5.8%

Drug of ChoiceDrug of Choice

N

Alcohol 24 11.7%

Amphetamine/ Methamphetamine 40 19.4%

Cocaine/ Crack 24 11.7%

Marijuana/ Hashish 5 2.4%

Opiates/ Opioids 93 45.1%

PCP 3 1.5%

Sedative/ Hypnotics 4 2.0%

Answered "multiple drugs" 13 6.3%

Relapse History

N % of all participants % of relapsers

Never Relapsed 57 27.7% Relapsed 149 72.3%

once 34 16.5% 22.8

twice 25 12.1% 16.8

3-5 times 29 14.1% 19.5

>6 times 61 29.6% 40.9

Drug Use HistoryDrug Use History

Age of Onset (%)

Identification of Problem (%)

1st (perhaps only) Recovery Attempt

(%)

5-11 years old 38.3% 1.5% 0%

12-14 years old 42.7% 11.6% 2.9%

15-18 years old 13.5% 35.0% 14.0%

19-21 years old 2.4% 12.6% 14.0%

22-25 years old 1.5% 10.7% 16.9%

26-29 years old 1.0% 7.3% 13.5%

30-40 years old .5% 16.5% 25.2%

41-49 years old

4.4% 11.1%

50-59 years old

.4% 1.9%

Comparison of Addicts and General Comparison of Addicts and General Population on Prevalence of Insecure Population on Prevalence of Insecure

AttachmentAttachment

N Observed Prop Test Prop. Asymp. Sig (1-tailed)

Insecure 12222

.59 .42 .OOOa Secure 84 .41

a- Based on Z approximation to binomial test.

Comparison on prevalence of insecure Comparison on prevalence of insecure

attachmentattachment

Table 16 Comparison of Caucasian Participants and General Population on Prevalence of Insecure Attachment


Insecure 74 .58 .42 .000a Secure 54 .42

a' Based on Z approximation to binomial test.

Table 17 Comparison of Non-Caucasian Participants and General Population on Prevalence of Insecure Attachment

a- Based on Z approximation to binomial test.


Insecure 48 .62 .42 .000a Secure 30 .38

Comparison of Family History Comparison of Family History PositivePositive (FH+) Addicts (FH+) Addicts vs Family History Negative (FH ) Addicts on Insecure vs Family History Negative (FH ) Addicts on Insecure

Attachment History (Hypothesis 2A)Attachment History (Hypothesis 2A)

Mean SD Std. Error t df Sig. Mean (1-tailed)

AHQCOMP

F H+ 119 203.56 26.32 2.41 FH- 87 211.56 24.53 2.63

-2.218 204 .014

Note. Lower scores on the AHQCOMP indicate less secure attachment.

Comparison of Family HistoryComparison of Family History Positive Addicts Positive Addicts (FH+) vs Family History Negative (FH ) (FH+) vs Family History Negative (FH )

Addicts on Current Attachment Style Addicts on Current Attachment Style (Hypothesis 2B)(Hypothesis 2B)

Attachment Style

F H+ FH- Total

Secure N 43 41 84 % within secure 51.2% 48.8% 100.0% % within FH+ 36.1% 47.1% 40.8%

Insecure N 76 46 122 % within insecure 62.3% 37.7% 100.0% % within FH+ 63.9% 52.9% 59.2%

Total N 119 87 206 57.8

% 42.2% 100.0%

100.0%

100.0% 100.0%

Note. x 2(1, N=206) = 2.514, p=.06.

Current Attachment Style by Length of Current Attachment Style by Length of Time Abstinent for All ParticipantsTime Abstinent for All Participants

N Securee

Ambivalent Avoidant

<10 years abstinent 103 32 27 44 within abstinent group 100% 31.1% 26.2% 42.7% within attachment style

55% 38.1% 61.4% 56.4%

> 10 years abstinent 103 52 17 34

within abstinent group 100% 50.5% 16.5% 33.0% within attachment style

44.5% 61.9% 38.6% 43.6%

Total 206 84 44 78


100% 100% 100% 100%

Note. x 2(2, N=206) = 8.317, p =.008.

Current Attachment Style by Length of Current Attachment Style by Length of Time Abstinent for Family History Time Abstinent for Family History

Positive ParticipantsPositive Participants

N Secureeee

Ambivalent Avoidant

<10 years abstinent 66 17 18 31 within abstinent group 100% 25.8% 27.3% 47.0% within attachment style

55% 39.5% 64.3% 64.6%

> 10 years abstinent 53 26 10 17

within abstinent group 100% 49.1% 18.9% 32.1% within attachment

style 44.5% 60.5% 35.7% 35.4%

Total 119 43 28. 48


100% 100% 100% 100%

Note. 22 (2, N=119) = 6.915, p=.016.

Family History Status (FH+ vs FH-) and Age of Family History Status (FH+ vs FH-) and Age of

OnsetOnset

N Mean SD Std Error t df N Mean SD Std Error t df Sig.Sig.

Mean Mean (2-tailed)(2-tailed)

________________________________________________________________________________________________________

Age of OnsetAge of Onset

FH+ 119 11.63 3.15 .29 FH+ 119 11.63 3.15 .29

FH- 87 13.68 4.16 .45FH- 87 13.68 4.16 .45

-4.03 204 -4.03 204 .000.000

Regression for Age of Onset of Regression for Age of Onset of UseUse

Step R-Square Change F Step R-Square Change F Change p_Change p_

Family History 1 .074 Family History 1 .074 16.23 .00016.23 .000

Security of Attachment 2 .046 Security of Attachment 2 .046 10.65 .001 10.65 .001

Comparison of Secure and Insecure Comparison of Secure and Insecure Attachment Styles on Age Alcohol or Attachment Styles on Age Alcohol or Other Drug Use was Identified as a Other Drug Use was Identified as a

ProblemProblem

Identified Problem <15 y.o.

Identified Problem > 15 years old

Total

Secure 4 80 84 within attachment style 4.8% 95.2% 100% within problem identified 15.4% 44.4% 40.8%

Insecure 22 100 122

within attachment style 18.0% 82.0% 100% within problem identified 84.6% 55.6% 59.2%

Total 26 180 206

within attachment style 12.6% 87.4% 100% within problem identified 100% 100% 100%

Note. x 2 (1, N=206) = 7.944, p =.002.

Comparisons of Participants with Secure and Comparisons of Participants with Secure and Insecure Attachment Styles on Perceived Insecure Attachment Styles on Perceived

Social SupportSocial Support

Perceived Social Support

N Mean SD Std. Error Mean

df Sig. (1-taileq)

Family Scale

Secure 84 2.45 .92 .10

Insecure 121

3.21 1.05 .10 5.312 203 .000

Friends Scale Secure 84 1.96 .66 .07

Insecure 121

2.19 .85 .08 2.114 200.30 .018

Sponsor Scale Secure 82 1.88 .76 .08

Insecure 118

2.18 .90 .08 2.462 198 .008

Note. Lower scores on all three scales indicate greater satisfaction with perceived social support.

Influence of Attachment on Addiction Addition and Psychiatry Seminars UCLA Donna Markus, Ph.D.

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