Addiction and Attachment Theory

Addiction appears in a myriad of forms. From the more recognizable abuse of

substances such as alcohol and drugs, to the more subtle and cunning instances of compulsive

sexual behavior and addictive relationships, the reality of addiction can be found in every

corner of society. Equal in variety to manifestations of addiction are sundry psychological

theories that attempt to explain and treat the problem. Blane and Leonard (1987) identify four

traditional models for understanding alcoholism (tension reduction theory, personality theory,

interactional theory, and social learning theory), as well as five theoretical models that were

emerging at the time of their writing.

An approach to understanding and treating addiction that has produced a great deal of

research in recent decades, and which shows great promise for effective treatment of those

who suffer with addictions, has come from attachment theory. This paper attempts to

articulate those aspects of attachment theory relevant to understanding addiction from its

theoretical perspective, define addiction in terms of attachment, and understand how addiction

is treated as an attachment disorder. Relevant research studies which seek to establish

addictions as a problem rooted in attachment and to examine the effectiveness of attachment-

oriented psychotherapy in treatment of addictions will be reviewed. Finally, this paper will

consider directions for future research.

Attachment Theory

In the 1940’s and 1950’s, the most prominent psychodynamic theories understood

pathology as being rooted in fantasy and intrapsychic conflicts between opposing impulses.

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Bowlby, drawing from his own observations of young children and work done in the field of

ethnology, began to conceptualize an alternative theory that argues attachment is a primary

drive rooted in biology, not fantasy. Specifically, he writes, “Psychological attachment and

detachment are to be regarded as functions in their own right apart altogether from the extent

to which the child happens at any one moment to be dependent on the object for his

physiological needs being met” (1958). Thus Bowlby asserts that attachment is rooted in the

biology of the human being and is not formed as a result of another function, such as the

provision of food from a caretaker to an infant. This postulation has been supported in

various studies. These include Harlow’s (1958) study with young monkeys who cling to a

terry cloth figure rather than a wire figure that has a bottle, and Spitz’s (1945) research on

orphans that showed infants provided for physically but lacking human interaction had a death

rate of seventy-five percent.

Advancements in technology and the field of neuropsychology have made even clearer

the primary nature of attachment for human beings. Researchers have found that attachment

can affect gene expression and the neural structure (Flores, 2004). Indeed, much like the

development of vision for infants or the ability to learn a second language for toddlers, the

process of attachment early in life activates and strengthens certain neural substrates that will

shape a person’s emotional experiences later in life. For example, Coan, Allen, and McKnight

(2006), reading data on asymmetries in prefrontal activity of insecurely attached infants of

depressed mothers, suggested that these infants already evidenced using avoidance as a

strategy for affect regulation.

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The Internal Working Model and Attachment Styles

Attachment theorists understand that early attachment experiences with caretakers and

the neurological and affective consequences of these experiences develop into an internal

working model of self and others. Bowlby (1973) understood the internal working model to

be based upon two independent variables: a judgment about the dependability and

responsiveness of the attachment figure, and a judgment about the worth of the self as the

object to which one would respond in a positive way. Over time, a consistent pattern emerges

between infant and caretaker, and this teaches the infant what to expect in the relationship.

Implied rules about staying in relationship with the caregiver are internalized by the infant,

and these become guides for how the infant will think, feel, and behave in future significant

relationships. Specifically, the internal working model shapes the strategies one employs in

an attempt to achieve a feeling of relational security between the self and others.

These relational patterns have been conceptualized as attachment styles. Ainsworth’s

(1969) well-known study of children in the “strange situation” was foundational as an

articulation of the four styles of attachment. Secure attachment is developed when a caretaker

shows awareness of a child’s emotions and quickly attends to the child when distressed. The

child perceives the caretaker as consistent in presence and provision. Securely attached

children feel the freedom to explore their world because they have a sense of certainty that

their caretakers are available, should they be needed. Insecure attachment is subdivided into

two styles: anxious-avoidant attachment and anxious-ambivalent attachment. Anxious-

ambivalent attachment manifests in high levels of distress at the absence of a caretaker, as

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well as anger and anxiety upon the caretaker’s return. The caregivers of anxious-ambivalent

children do not attend to their children’s emotional needs in consistent or appropriate ways.

At times, these caregivers actually look to their children for support or a sense of worth and

approval. Anxious-ambivalent children cling to their caregivers and do not exhibit a capacity

for exploration. Anxious-avoidant children show little or no distress when separated from a

caregiver and, upon the caregiver’s return, will avoid contact. Their caregivers typically

ignore or deflect requests for comfort, maintain a greater degree of physical distance from the

child, and sometimes only attend to the children based on achievement. In Ainsworth’s study,

these children did play with the toys, but with much less enthusiasm than those children with

secure attachments. Later studies delineated the anxious-avoidant attachment into two

different expressions, each distinguished according to its defenses (Bartholomew, 1990). The

fearful-avoidant has high anxiety about himself, desiring closeness but allowing fear of

rejection and/or abandonment to prevent relational intimacy. The dismissing-avoidant, on the

other hand, tend to view themselves more positively and others more negatively, believing

others are not worthy of trust.

Adult Attachment Styles

Important to attachment theory is the assumption that the experiences of childhood

relationships shape adult attachment style. Those with a more secure attachment as children

tend to have attachment security as adults; those from more unstable, insecure environments

are more likely to exhibit insecurity. A continuity has been found between child-caretaker

relationships in childhood and intimate relationships between adults (Main, 1995).

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Ambivalently attached adults are typically “needy” in their relationships and are more likely

to very quickly feel “in love” with another. They are preoccupied with their relationships,

constantly pursuing assurance from their partners or friends. Adults with an avoidant

attachment styles, however, resist investing emotionally in and committing to relationships.

But securely attached adults--those with a positive regard for self and others--are comfortable

with both relationship and solitude, for they have achieved the developmental goal of

attachment: a capacity to be intimate and autonomous (Flores, 2004).

Understanding Addiction through Attachment Theory

To understand addiction, attachment theorist begin by asking the fundamental

question: “Why?” Why do alcoholics drink? Why does the compulsive eater continue his

trips to the fridge; the gambler, her feeding of the slot machine; or the sex addict, his loveless

rendezvous with a stranger? In moments of clarity, every experienced addict anticipates the

sense of shame he or she will feel after acting out. Yet addicts feel compelled to act out and

unable to stop themselves. Alcoholics frequently exhibit a pathology of depression, anxiety,

and relational issues. For years, these were understood as causes which drove people to drink.

However, thinking has shifted in recent decades after seminal studies such as that of Vaillant

(1983), who concluded, “Most of the psychopathology seen in the alcoholic is the result, not

the cause of alcohol abuse” (p. 317). The problems once thought to be what drove people

toward addiction have been found to be symptoms that will abate when the addict abstains. A

different origin of addiction is required.

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Affect Regulation and Addiction

Attachment theorists suggest the normal, biological need for mutual affect regulation

as a starting point in understanding addiction. Bowlby (1979) claimed that secure

attachments are necessary for human affect regulation throughout life, not just in infancy and

early childhood. Indeed, research has shown that the attachment system’s affect regulating

work is essential for the conservation of cognitive resources; humans can self-regulate for

only so long before their capacity to do so is significantly weakened (Coan, 2010).

If all humans need mutual affect regulation, and successful affect regulation is

dependent upon secure attachments, it follows that adults with insecure attachment styles will

have problems with affect regulation. Without the capacity for both intimacy and autonomy,

insecurely attached adults will respond to their difficulty in forming relationships that meet

the biological need for emotional management by searching for something else to control their

affections (Flores, 2004). This problem is compounded by the negative emotional

experiences of those with insecure attachments, who typically feel anxious, unworthy, and

ashamed of themselves or their behavior. Such an affective state is intolerable for any length

of time, and the insecurely attached adult, because of his or her unmet developmental need,

lacks the capacity to turn to relationships to help mediate these intense emotions. Thus this

person will relentlessly pursue external sources of regulation in an effort to self-medicate his

or her emotional pain.

Addiction, then, can be understood from an attachment perspective as an attempt to

regulate affect which ultimately fails and reinforces the very relational problems from which

the negative affective state stems. For example, if Bill is insecurely attached and exhibits the

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feelings and behaviors of someone who is preoccupied or ambivalent, he may attempt to

medicate his feelings of anxiety and inferiority and fear of abandonment with drinking.

However, if his drinking becomes compulsive, it will likely result in damage to his existing

relationships that serves to reinforce in his mind the dangers of attachment.

Treating Addiction as an Attachment Disorder

The aim of psychotherapy from the perspective of attachment theory is to provide a

corrective relational experience which will modify the client’s internal working model and the

implicit rules and patterns which guide all of his or her close relationships. The goal of

therapy is to help the client attain that optimal balance of intimacy and autonomy, the ability

to be relationally close to others and independent. The therapeutic relationship becomes an

opportunity for the client to experience an attachment in which they feel another person is

attune to their emotions. The therapy environment becomes a holding environment, in which

the client’s emotions are validated but the client is also given the opportunity to learn to self-

soothe (Flores, 2004).

The Early Stage of Therapy

If addictions are attempts of affect regulation by insecurely attached individuals, as

argued above, then attachment theory’s therapeutic aim to help clients form secure

attachments should prove effective in the treatment of addictions. However, the first task of

the therapist in working with an addict is to create the capacity for secure attachments. Before

a significant relationship with a therapist can begin, the client must end the relationship with

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the substance or behavior to which she or he is addicted. Mere logic and argument will rarely

succeed in bringing an addict to a point of sobriety. Instead, addicts must come to experience

benefits and pleasure of sobriety that outweigh the short-term gains of indulging in their

addictions. This often occurs when an addicts reach their “bottom,” a point at which the pain

caused by their addictive behavior brings about a moment of clarity, which opens a window of

willingness to take risks in an effort to get help.

Flores (2004) points out that insecurely attached adults who desire treatment for

addiction can find the thought of individual therapy overwhelming and frightening, making

group therapy or the fellowship of a Twelve Step program a safer place to begin recovery.

The prospect of being one of many and having the ability to somewhat blend into a group

rather than be the focus of attention makes group settings less threatening. Eventually, these

options are also beneficial in their opportunity for providing relationships in which an

individual can receive the support and connection needed for affect regulation and a sense of

security.

Another component of the early stages of therapy is the treatment of alexithymia, the

inability to process and articulate the emotions one feels. Attachment theory’s understanding

that emotional capacity is developed through secure attachments explains well the frequent

incapability of addicts to identify and express their affective states. Instead, the addict only

knows that she or he feels pain, and this intense displeasure is medicated through the use of

substances or participation in behaviors that block the emotions (Flores, 2004). Thus the

addict never heeds the message behind the negative affect and works to resolve the root cause.

During the early stages of therapy, the therapist can help the client overcome alexithymia by

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mirroring the client’s affect and guiding the client toward discovering a label for the formerly

nameless emotional pains. From the perspective of attachment theory, the experience of

having emotions acknowledged and mirrored was likely rare or absent in the formative

experiences of a client’s childhood, and the therapist can provide that experience of having an

attentive object that is consistently responsive to the affective needs of the self.

The Later Stage of Therapy

The goal of the early stage of therapy is to aid the client in gaining the capacity for a

meaningful attachment relationship; the goal of the later stage of therapy is the creation of

such a relationship. The therapist can foster this attachment by helping the addict develop a

capacity for self-care. Inside a secure attachment relationship, the client is more able to

discern his own emotional state with the help of the therapist, and this can then be extended

into learning the skills of self-care. Addicts are emotionally isolated not only from others, but

also from themselves. As the therapist helps her client understand emotions as prompts to

inner needs, the client’s heightened self-awareness can lead to increased self-care.

But with heightened self-awareness comes danger for the addict. According to Flores

(2004), relapse during the later stage of treatment most often occurs when the addict feels

either too good or too bad too quickly. Feeling too good can fool an addict into narcissistic,

defensive thinking that reasons he is different than other addicts, superior to them, and has the

ability to control his behavior. Feeling too bad too quickly can drive an addict back to his

drug of choice. Thus it is crucial for the therapist to regulate the pace of affect experience so

that clients avoid these two extremes as she guides clients in discovering the internal roots of

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the addictive behavior: specifically, how the addiction served as a means of affect regulation

in the place of a secure attachment and why secure attachments are a difficulty.

This process of discovery certainly requires a conversation in which the client and

therapist work together for increased levels of awareness about the origins of the client’s

insecure attachment style, but attachment theory believes this awareness is not the primary

source of change. Instead, the therapeutic relationship in which the client actually

experiences security attachment and learns to work through emotional discomforts and

conflicts is the real force behind change. The therapist becomes a transformational object

(Flores, 2004), helping the client to reform his conceptualizations of self and others, which in

turn modifies his internal working model and the implicit rules of his relationships.

Successful treatment will include the client accepting the need for close relationships for

emotional health and cultivating the capacity to develop such relationships from his available

social resources.

Review of Relevant Research Studies

Much work has been done in recent decades on both the conceptualization and

treatment of addiction from the perspective of attachment theory. Below is a review of five

research studies that examine various connection points between addiction and attachment.

Affect Regulation and Attachment

A key study by Brennan and Shaver (1995) considers the affects of attachment style on

the experience of romantic love. Among the topics addressed in their extensive study was the

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use of affect regulation behaviors by those with an insecure attachment style. They

specifically looked at three such behaviors: nonintimate sexual encounters, alcohol

consumption for the purpose of reducing tension or anxiety, and over- and under-eating.

Subjects for Brennan and Shaver’s study included 242 college students who were

selected based on their attachment style, as indicated by the results of Hazan and Shaver’s

(1987) categorical attachment-style measure. The pool of participants included approximately

equal numbers of each attachment style: avoidant, anxious, and secure. They were then asked

to complete various scales to determine their sexual attitudes and behaviors, drinking behavior

and motives, and maladaptive eating behavior, as well as several additional measure of

attachment and relational satisfaction. Results showed that those who act out nonintimate

sexual behaviors are more likely to be avoidant and have higher degrees of ambivalence,

frustration, self-reliance, and clinginess. Also, avoidant and ambivalent attachment styles

correlated positively with coping drinking behaviors, as did jealousy, clinginess, frustration,

ambivalence, and self-reliance. Similar results were found around the affection regulating

behavior of eating disorders. The findings of this study by Brennan and Shaver support the

theory that addictive behavior is rooted in a need for affected regulation in those adults who

exhibit insecure attachment styles.

A more recent study (Molnar, Sadava, Decourville, & Perrier, 2010) examined the

relationship between attachment styles and problem drinking. The authors of this study

specifically look at a dual-path model of high-risk drinking, which attributes two motivations

to problem drinking: a social component of desiring to fit in and avoid rejection, and an

affective component of enhancing positive affect and numbing negative affect (emotional

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regulation). They hypothesized that, based upon the premise of attachment theory, ambivalent

and avoidant attachment styles would be more likely to use alcohol for affect regulation and

experience problems in drinking behaviors.

The sample included 696 students self-identified as drinkers, as well as a clinical

sample of 213 inpatient clients who were being treated for alcohol abuse for the first time.

They were given the Relationship Scales Questionnaire, which measures adult attachment

orientation, and the revised Drinking Motives Questionnaire, which looks at enhancement,

coping, social facilitation, and social conformity as motives for drinking. As expected,

participants who had insecure attachment were more likely to participate in high-risk

drinking.

Because this study looked at a dual-motive to problem drinking, however, its results

yielded an interesting conclusion. Among those individuals who had higher scores in

avoidance, there was a significant association with lower scores in social motivations behind

drinking. Those who scored high in attachment anxiety but low in avoidance, on the other

hand, had a significant association with both the social and affective motives to drink. This

fits in the attachment theory model, as anxious-ambivalent (preoccupied) attachment style is

more concerned about seeking approval and gaining a sense of worth from others.

A 2009 study by De Rick, Vanheule, and Verhaeghe asked whether alcoholic inpatients

could be differentiated based on a combination of their attachment style and degree of

alexithymia (the inability to process or identify affect). Secondly, the researched explored

whether these subsets of patients would differ in their degree of problems related to alcohol

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(as measures by the European Addiction Severity Index) and psychiatric disorder commonly

associated with alcoholism, namely, anxiety, depression, and personality disorders.

Participants in the study included 101 patients admitted to six psychiatric hospitals

between September 2003 and December 2004. In addition to the European Addiction

Severity Index, they were also given the Adult Attachment Style Questionnaire to measure

attachment style and the Bermond-Vorst Alexithymia Questionnaire to measure inability of

affect regulation. The results yielded the designation of three subgroups of alcoholic

inpatients. Group 1 consists of those who have an impaired attachment system and high

degree of alexithymia and inability to secure interpersonal relationships. Group 2 consists of

individuals with moderately functioning representational systems and a degree of difficulties

in affect regulation or interpersonal functioning. Finally, group 3 includes those with a well-

established attachment system and an ability to regulate affect effectively.

This study showed that a majority of alcoholic inpatients were group 1 (52%), while

few were in groups 2 (34.5%) and 3 (13.5%). Thus most of the participants were determined

to have moderate to high impairments in their attachment systems and affect regulation

abilities. They also found, however, that no correlation exists between these three groups and

the experience of alcoholism’s severity or duration. From this, the researchers concluded that

alcoholism is not the result of an attachment disorder, that problems in attachment style exist

prior to the onset of alcohol addiction, and they strongly suggested that treatment for patients

be based upon knowing to which of these three groups each patient belongs.

A fourth study that considers the relationship between attachment style and affect

regulation, though from a different starting point, was done by Smith and Ng (2009).

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Building off the large body of work showing that attachment style is largely based on early

family experiences, this study sought to specifically examine the relationship between

attachment styles and the perceived emotional expressiveness on an individual’s family of

origin. The researchers expected to find a relationship between securely attached individuals

and higher levels of perceived affect expression in their families of origin.

Participants included 279 individuals, ranging in age from 18 to 45 years and from at

least six ethnic backgrounds. They were all given the Experiences of Close Relationships, a

self-report questionnaire developed to measure adult romantic attachment in terms of

avoidance and anxiety. They were also give the Family-of-Origin Expressive Atmosphere

Scale, a self-report measure of perceived affect expression in the participant’s family of

origin.

Results showed, as the researchers expected, that those participants with secure

attachment styles reported higher levels of emotional expression in their families of origin and

viewed that expressiveness more positively than participants with fearful and preoccupied

attachment styles. However, those with dismissive attachment styles had no significant

differences in reported family of origin expressiveness. While this was not what the

researchers expected, they note that it is consistent with other studies that show dismissive-

avoidants have a tendency to recall only a small portion of their childhood (usually only

positive experiences) and idealize their parents. Overall, this study supports the

understanding of the relationship between attachment and affect regulation, looking

specifically to the environment in which one’s attachment system is first developed, the

family of origin.

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Addiction, Attachment, and Twelve Step Recovery

The popularity of Alcoholics Anonymous (AA) and other Twelve Step programs in the

treatment of addiction has prompted many studies of its effectiveness and model for change.

Interestingly, many components of Twelve Step recovery run parallel to the understanding of

addiction and treatment from the perspective of attachment theory. Smith and Tonigan (2009)

conducted research on the effectiveness of AA participation on one’s degree of attachment

anxiety, avoidance, or security.

Smith and Tonigan begin their article by highlighting points of connection between

AA’s model of fellowship recover and attachment theory. Specifically, AA places a great deal

of importance on the social support offered in the fellowship. Relationships are central to the

Twelve Step program. Only the first the steps mentions alcohol; the others all deal with

relational concepts of humility, authenticity and service, which promote the establishment of

authentic social relationships. The authors also note that most people enter AA during a time

of intense emotional uncertainty, a time when changes to attachment style are possible. Their

prediction was that involvement in AA would be associated with lower levels of avoidant and

anxious-ambivalent attachment and higher levels of secure attachment styles. Also, they

believed that AA exposure and practices would bring about changes in these attachment

styles.

Participants included 158 individuals who had been patients at a large addiction

treatment facility and had attended at least 30 AA meetings. Ages ranged from 21 to 82 years

old. They were given adaptations of Hazan and Shaver’s (1987) attachment style measure

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that assessed their pre-AA attachment and post-AA attachment. They found that AA

involvement leads to a significant increase in ratings of secure attachment and a significant

decrease in ratings of anxious and avoidant attachment. Thus the researchers conclude that

AA involvement is related to a greater level of security and mutuality in close relationships.

The results of the study also showed that mere attendance to AA meetings did not create these

same results, but full participation in the AA program--which involved close engagement with

others in the program--accounted for changes in attachment style. Smith and Tonigan see

involvement with an AA sponsor, working the steps, and fellowship outside the meetings as

relational activities that can lead to improvement in other relationships.

Recommendations for Future Inquiry

The research summarized above contributes significantly to the understanding and

treatment of addiction using the model of attachment theory, however the limitations of these

and other studies point the direction for future research questions. The study done by Molnar

et al. gives place to motivations other than affect regulation for coping drinking behavior,

specifically, a motivation to fit in socially and avoid rejection, among those with a

preoccupied attachment style. This conceptually fits within attachment theory’s

understanding of the preoccupied attachment style, which is continuously seeking reassurance

and security from its object out of a desire for approval and fear of rejection. If these social

concerns contribute to problem drinking as much as the desire for affect regulation, how

might similar social concerns play into other forms of addiction? Would the same motivations

show up in eating disorders, compulsive sexual behaviors, or gambling?

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A question raised by the study by De Rick et al. concerns how the treatment of their

proposed three differing groups of alcoholics would be articulated. As these various treatment

plans evolved, would researchers be able to find points of connection between the treatment

of patients in group 1 (those with severe insecurities in attachment and a high degree of

alexithymia) and patients in group 3 (those with healthy attachment systems and strength in

affect regulation)? If certain commonalities exist, what might they imply about the universal

nature of addiction, and how would these universal implications affect the attachment theory

of addiction?

Finally, while Smith’s study on the effectiveness of AA participation on attachment

style is certainly interesting, it could be improved methodologically. The study administered

a survey containing a self-reporting measure of pre- and post-AA attachment styles. Far more

effective would be a study of participants over time, tracking them upon entry into a recovery

program, throughout the program, and for some time afterward. The method used in Smith’s

research leaves room for subjective reporting, misremembering, and does not account for

long-term change.

Finally, the understanding of addiction from the perspective of attachment theory

could be applied to codependent relationships in helpful ways. Addictive relationship, I

believe, are far more prevalent in society than alcoholism or drug abuse, and are increasing

because of the effects of technological developments in the area of communication and social

networking. Adults and teenagers both check Facebook and send text messages with a

compulsion that certainly appears addictive. How is technology changing the way humans

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interact and form attachments, and how is this change affecting our brain chemistry, neural

developments, and ability the regulate affect?

Of great concern with this explosion of social networking technology and its

compulsive use by so many in our society is how it creates the illusion of intimacy and

closeness with others while actually preventing it in many cases. Can a parent who never puts

down her Blackberry mirror her infant’s emotions sufficiently to allow the development of

secure attachment? Can young adults who text their friends throughout a first date really get

to know their dinner partners? Perhaps future research can examine the compulsive behavior

elicited by social networking and communications technologies and investigate the impact of

this behavior on our ability to form meaningful attachment relationships.

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