Attachment Among Aca

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Addiction (1993) 88, 1405-1411

RESEARCH REPORT

Attachment among adult chi ldren of alcoholicsNADY EL-GUEBALY, MALCOLM WEST, ELEANORMA TICKA-TYNDALE, & MARY PO OL

Hospital, Calgary, Alberta, Canada

relationships have been identified as a predominant feature of adult children oalcoholics (ACO As). Recently, the concept of co-dependency has been advanced to depict the interpersonthese individuals, but lacks definitional rigor. The notion that childhood experiences with pareforward' to affect attitudes a nd behaviors relevant to later intimate relationships is also consisteent theory. This study exam ined the pattems of attachment of ACO As as compared to adultof non alcoholics (ACONAs). A cross-sectional sample of 203 individuals attending either a shor

ent psychiatric program or a comm unity based alcoholism treatment program teain this study. Results supported the hypothesis that female ACO As had a d istinctive dysfunctionalwere no significant differences in the attachment styles of male ACOAs as comparACO NAs, or male substance abusers as compared to non-abu sers.

et al.,1978; Frances, Timm & Bucky, 1980; El-Gue-et al., 1990). The co-dependency concept

se na ttire of co-dependency and its relation-

higher incidence of various fortns of emotionalproblems, psychiatric disorders (Frances et al.,1980; El-Guebaly et al., 1991) and in particularthe higher incidence of substance abuse amongACOAs (Nylander, I960; Rydelius, 1981;Schulsinger et al., 1986) as compared to theadult children of non-alcoholics (ACO NAs). Ad-ditionally, there is a growing literature which iscritical of co-dependency as a potentially gender-biased construct (e.g. Asher & Brissett, 1988;Van Wormer, 1989; Wright & Wright, 1990).Such critiques are based on the differential im-portance of relationships to the development ofselfhood in men and women as described by


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1406 Nady El-Guebaly et al.clarify the nature of the relationship problems ofACOAs should explore the potential value ofattachment theory. A recent study by Brennan,Shaver & Tobey (1991) confirmed the specialimportance of the attachment construct to thetmderstanding of the relationship problems ofACOAs. Undergraduate college students whoreported parental problem drinking scored highon both avoidant and anxious-ambivalent attach-ment pattems.

TTiis paper furthers Brennan et al.'i explo-ration of the relationship between attachmentand ACOA status using an outpatient psychiatricpopulation. It reports the results of an empiricalstudy which investigated the distinctive attach-ment profile of ACOAs as compared toACONAs.Attachment and parental alcoholismAlthough most attachment research has con-centrated on child-parent relationships, allattachment theorists acknowledge attachment tohe an important feature of adult relationships(Henderson, 1977; Weiss, 1982; Ainsworth,1989). Furtherand criticallythe function ofattachment remains unchanged from childhoodto adulthood; that is, proximity to a special andpreferred other is sought or maintained in theexpectation of finding security (Sheldon & West,1989). The sense of security in any attachmentrelationship depends upon the quality of respon-siveness experienced with that partner.

From this standpoint, the interpersonal prob-lems of the ACOA may refiect adaptations toand ways of dealing with a troubled familialenvirotiment leamed over many years(O'Cotinor, Sigman & Brill, 1987). Further, theseverity of the ACOA individual's interpersonalproblems may reflect the rigidity and pervasive-ness of the relational difficulties within the familyacross the span of years from childhood throughadolescence to adulthood. Long-continued andmultiple stresses such as the inability of thealcoholic parent to respond empathetically, par-entification of the child or repeated threats ofabandonment may lead to long-term relationaldifficulties.

been given special pressure for continuthrough having been validated by both subsquent attachment events in the family aexperiences within other relationships (i.e. tdegree of success in havitig attachment neemet). Thus successive relationship experiencinteract with prior experiences, through the reresentational model, to determine tindividual's current state of mind with regard attachment.In the instance of ACOA individuals, contued lack of success in achieving felt securreitiforces their pessimistic beliefs about attacment. Because of their strength, these affectivecharged beliefs about attachment exist as potential awaiting expression in currerelationships. In sum, the attachment expeences of the past and the content of preseattachment relationships are formulated ainterpreted in terms of the ACOA individuarepresentational model of attachment.One direct manifestation of the effect of themodels is the defensive organization of attacment into panems of relating. Althougvariously named, insecure attachment pattemacross the life span move from the distant, d

tached to the close, enmeshed. In adults, Bowl(1977) has described three pattems of insecuattachment: anxious attachment, compulsiself-reliance and compulsive care-giving. He halso referred to a balance between anxious anangry attachment from which an ambivalent patem appears to arise.This study explored the relevance of tattachment construct to understanding tlong-term impact of alcoholism on children

alcoholics. Three hypotheses were tested.Hypothesis 1: ACOAs and ACONAs scoreferently on measures of attachment.Hypothesis 2: ACOAs demonstrate more dfunctional attachment styles than ACONAs.Hypothesis 3: Severity of itnpact of parealcoholism on children is associated with severiof dysfunction in attachment.

MethodsSelection of p articipants


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Attachmen t amon g adtilt children of alcoholics 1465, seeking any one of a variety of short-termtherapeutic services of a hospital based outpa-tient psychiatric program (n = 118) or acommunity based alcoholism treatment program(n = 85). All such services are available withoutpayment of a fee as part of Canada's universalhealth and social service system.Potential participants were approached at thehosp ital or trea tment cen tre. Th e study vsras ex-plained and informed, written consent wasobtained prior to proceeding. Individuals withsignificant physical illness, intellectual impair-ment, or active psychoses were excluded fromthe study. Eighty percent of those approachedmet study criteria, agreed to participate, andcompleted the research instruments describedbelow in one or two sessions separated by lessthan two weeks. Recruitment spanned a periodof 18 months. Clinical responsibility for all par-ticipants remained with the clinical stafF of therespective programs.Sample profileThe sample of 203 consisted of 93 (46%) menand 110 women. The mean age for both genderswas 36.6 years, mean education 14 years andmean Blishen occupational ranks (Blishen &McRoberts, 1976) 39.8 for men and 39.2 forwomen. TTiese occupational ranks indicate lowermiddle and upper working class occupations re-quiring 12-15 years education. Fifty-one percentof those sampled were ACOAs. Sixty percent ofthe men and 37% of the women were substanceabusers. Chi-square and t-tests showed thatACOAs and ACONAs did not differ significantlyin sex, age, education, occupation, marital statusor substance abuse.

Scores on the Millon Clinical Multiaxia! In-ventory (MCMI), a clinical assessmentinstrument described in the measurement sec-tion, produced profiles consistent with those of ahelp-seeking population. The most prevalent dis-orders were dysthymia and anxiety. Analysis ofcovariance of the MCMI scores revealed nosignificant differences in disorders related to sex,age or occupation. Psychopathology, as mea-sured by the MCMI, was not significantly

Sheldon, 1988; West & Sheldon-Keller, 199was used to assess the component features attachment in adults, that is, their style of anacment to a peer. Drawing on the work of Bowl(1977), Ainsworth (1989), and Weiss (1982West et al. operationalized the key componenof reciprocal attachment as self-report scales. the RAQ, an attachment figure is defined aspeer who is not a m ember of the family of origwith whom there is usually a sexual relationshand with whom there has been a special relatioship for at least 6 months. Instructions respondents include a description of an attacment figure as "the person you would be molikely to tum to for comfort, help, advice, love understanding; the person you'd be most liketo depend on, and who may depend on you fsome things; the person you feel closest to rignow."

Four subscales (separation protest, feared losproximity seeking, and reciprocity) relate to tcriteria of attachment and serve to distinguiadult attachment from other social relationshipTwo subscales (use of the attachment figure aperceived availability of the figure) relate to tunique provisions offered by attachment. Finalfour scales assess the four identified pattemof dysfunctional attachment relationships fadult: compulsive self reliance, compulsive carseeking, compulsive care-giving and angwithdrawal. The pattems, criteria and provisioare further defined in Table 1.The RAQ consists of 46-items each rated on5-point likert-type scale. Summation scores ften separate scales are produced. Six scales

three items each relate to the unique criteria anprovisions of reciprocal anachm ent relationshipwith scores varying from 3 to 15. Fou r scales 7 items each relate to dysfianctional pattems reciprocal attachment, with scores varying fro7 to 35.As reported in detail in earlier publicatio(West et d., 1987; West & Sheldon, 1988; We& Sheldon-Keller, 1992), the validity and reability of the RAQ has been established wi

clinical and non-clinical adult populationAcross these sets of subjects, coefficient alp


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Attachment among adult children of alcoholics 140(3) The Millon Clinical Mu ltiaxial Inventory(MCMI; Millon, 1987) is a 175 item, true-falseinventory that follows the multiaxial format em-ployed in the DSM-III. Eleven personalitydisorders, nine clinical syndromes, and onevalidity scale are provided. The MCMI scales

were constructed and validated to measureDSM-IIi typologies (Dana & Cantrell, 1988).An issue, however, is the relative lack ofspecificity reported in Volume II of the Millonmanual for the alcohol and drug subscales (Mil-lon, 1987). The false positives and negatives are34% and 44% respectively for the alcohol scaleand 37% and 48% respectively for the drugscale. Consequently, substance abuse was mea-sured using twelve items from these two scaleswhich matched with DSM-III-R criteria for sub-stance abuse. The twelve items were subjected totests of face validity, discriminate validity, andinternal reliability. In the first instance, the con-gruence of the items and DSM-III-R criteria forsubstance abuse was assessed by experiencedclinicians. In the second, the ability of the twelveitem scale to discriminate between knovm sub-stance abusers and non-abusers was assessed.Finally, a Cronbach alpha of 0.89 demonstratedan acceptable level of internal reliability of thetwelve-item tneasure.

Statistical analysesData were analyzed separately for males andfemales. Substance abuse was entered into dataanalysis as a control to test and measure itsimpaa on relationship pattems, distinct fromthat of ACOA status. T-tests, analyses of vari-ance, chi-square contingency tables andcorrelation analyses were used to assess the rela-tionships between attachment, ACOA status,severity of impact of parental drinking, and sub-stance abuse. A Bonferroni correction was usedto protect against chance effects in multiple test-ing, setting the p value at 0.05.ResultsPresence and characteristics of attachment figureTwenty-eight percent (56) of those sampled didnot have an attachment figure. Chi-square tests

spouse (53%) or other sexual parmer (30%). Anadditional 12% identified a same sex friend as anattachment figure and 6% a relative other thanthe spouse. Eighty percent reported the attachment relationship was over a year's duration, thlongest having endured for 43 years. Chi-squaretests demonstrated no significant differences inthe characteristics of the attachment relationships with respect to ACOA status, substancabuse or gender.

ACO A status and attachment pattems anddimensionsTable 2 presents results of comparisons of RAQscores for the 147 ACOAs and ACONAs witattachment figures. For women, ACOAs andACONAs were significantly different in theiscores on angry withdrawal, separation protesuse of the attachment figure, and perceivedavailability of the attachment figure. Nsignificant associations were found for men.Analyses of variance using both ACOA statuand substance abuse were conducted for maleand females separately to assess for possible interactions between substance abuse and ACOAstatus. Results indicated no significant differencin RAQ scores for women based on whether thewere or were not substance abusers, nor anyinteractions between substance abuse andACOA status. Only the association with ACOAstatus was significant. For men, none of thassociations were significant.

Severity of impact of parental alcoholism andattachmentSpearman rho correlations between CAST anRAQ scores were calculated for male and femalACOAs. Application of the Bonferroni correction required p-values at 0.005 or lower fosignificance at the 0.05 level. Once the correction was applied, none of the correlations mecriteria for significance. Four of the correlationfor male ACOAs, however, approachesignificance, suggesting further study with larger sample is warranted. These were the correlations between CAST scores and compulsiv


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1410 Nady Bl-Guebaly et al.Table 2. T-test results for ACOA/ACONA differences in RAQ scores

R A Q

RAQ pattemsAngry withdrawalCompulsive self relianceComptUsive care-givingCompulsive care-seekingRAQ dimensionsSeparation protestFeared lossProximity seekingReciprocityU seAvailabilityn

ACONA

17.8619.2823.1015.907.418.388.035.797.247.3429

MaleACOA

17.0018.3223.7117.037.949.218.885.246.267.2934

t

0.670.77- 0 . 6 3- 1.12- 0 . 7 5- 1 . 0 3- 1 . 5 51.301.890.08

ACONA

16.4417.0724.3417.536.687.898.844.755.406.6!4 5

FemaleACOA

20.0318.5824.0518.358.359.339.055.406.558.234 0

t

- 2.82*- 1 . 5 30.370.78- 2.57*- 2 . 0 70.37- 1 . 8 3-2 .57*-2 . 5 9 *

* p < 0.005 (required for Bonferrotii adjustment to f < 0.05).DiscussionThough the presence or absence of an attach-ment relationship did not differ for ACOAs andACONAs, for those who had an attachmentfigure, parental alcoholism influenced the attach-ment style (as measured by the RAQ) with whichthey approached their attachment partner. Forwomen, the presence of an alcoholic parent wasassociated with elevated scores on angry with-drawal and separation protest, and scoresindicating less use of the attachment figure forsupport and a perception of the attachmentfigu re as unavailable. All of these are evidence ofa dysfunctional attachment style, supportingboth hypotheses 1 and 2 for women. For men,though there were no statistically significant rela-tionships, the association between certainattachment dimensions and pattems and theseverity of the impact of the alcohol abuse (asmeasured by the CAST score) when there wasan alcohol abusing parent approachedsignificance. Approaching significance are the as-sociations between the severity of the impact ofalcohol abuse on the male offspring of an alcoholabusing parent and elevated compulsive self re-liance, low separation protest and use of theattachment figure for support, and a perceptionof the attachment figure as unavailable. Thoughhypothesis 3 is not supported, these results sug-gest further research, with a larger sample,

Bowlby (1977) as separation anxiety. In particular, the perception of the inaccessibility of theattachment figure and the angry withdrawal othese women from their attachment figure aranalogous to Ainsworth's anxious-resistant children who seek contact veith mother, but arcontact resisting and angry during the reunionepisode. This attachment style is also congruenwith Brennan et al. 's finding of an 'anxious-ambivalent' pattern among their ACOA subjectsThese findings provide empirical support foBrown's (1991) argument and Bretman et cU(1991) preliminary findings that the attachmenconstruct offers a specific, theoretically groundedway to understand and address the impact ogrowing up with an alcoholic parent.Turning to men, though restilts are not statis

tically sigtiificant for a sample of this size, apicture of an association between greater severityof impact of parental alcoholism and compulsiveself-stifficiency is suggested. Of note is the complementarity of the styles for men and women.The present study was a preliminary investigation of the utility of attachment theory inspecifying the natu re of the impact of growing upwith an alcoholic parent. These results are limited in their generalizability by the nature of thesample and that of the instruments usedSpecifically, the sample was drawn from a helpseeking adult population. DetaUs of childhood


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Attachment among adult children of alcoholics 1411coholic mothers as compared to fathers, the ageof the child when infiuenced by parental alco-holism, and the length of exposure to an artivelydrinking parent were not available. The genderdifferences in our results suggest a need forfurther exploration of the differential impact ofparental alcoholism on sons and daughters. Suchexploration should also take into considerationthe gender of the alcohol abusing parent, thespecific infiuences on the parent-child relation-ship and potential alternate adult-childrelationships.

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fancy, American Psychologist, 4 4 , p p . 7 0 9 - 7 1 6 .ASHER, R. &BRISSETT, D . (1988) Co-depen dency : aview fi"om wom en married to a lcoholics . InternationalJournal of Addiction, 2 3 , p p . 3 3 1 - 3 5 0 .BusHEN, B. & MCROBERTS, H . ( 1 97 6 ) A revised so-cioeconomic index for occupa t ions in Ca n a d a ,Canadian Review of Sociology and Anthropology, 13,pp . 7 1 - 7 9 .

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Attachment s tyles , gender and parental problemdrinking. Journal of Social and Personal Relationships,8, pp. 451^66 .BROWN, S. (1988) Treating Adult Children of Alcoholics:A Developmental Perspective (New York , S. (1991)Co - d e p e n d e n c e and ACAs: theoret ical expansionfrom an in terpersonal perspective. Paper presented atNational Consensus Symposium on Children of Alco-holics and C o-depend ence, Airlie, Virginia.CHODOROW, N. (1978) The Reproduction of Mothering:Psychoanalysis and the Sociology of Gender (Berkeley,CA, Universi ty of California Press).DANA, R . H . & CANTRELL, J . D . (1988) An upda te onthe Millon Clinical Mult iaxial Inventory (MCMI),Journal of Clinical Psychology, 4 4 , p p . 7 6 0 - 7 6 2 .EL-GUEBALY, N . , WALKER, JR., R oS S, C . A . & CURRTE,R . F. (1990) Adult children of problem drinkers inan u rban communi ty , British Journal of Psychiatry,

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286, pp. 1-89.S C H U L S I N G E R , F. , K N O P , J., G O O D W I N , D. , T E A S D A L ET. & MiKKELSON, V. (198 6) Aprospective study oyoung men at high risk for alcoboUsm, ArchiveGeneral Psychiatry, 4 3 , p p . 7 5 5 - 7 6 0 .SHELDON, A. & W E S T , M . (1989) Th e functional d iscrimination of attachment and affiliation: theory and

empir ica l demons t ra t ion , British Journal of Psychiatry, 155 , pp . 1 8 - 2 3 .STALEY, D . & EL-GL'EBALY, N . (1991) Psychometr ievaluation of the Children of Alcoholics ScreeningT e s t ( CAS T ) in a psychiatr ic sample. InternationaJournal of Addictions, 2 6 , p p . 6 5 7 - 6 6 8 .V A N W O R M E R JK . (1989) Co-dependency: implicat ionfor women and therapy. Women and Therapy, 8, p p5 1 - 6 3 .WEISS, R . (1982) Atta chm ent in adult l i fe , in : PARKESC. M. & STEVENSON-HINDE, J. (Eds) The Place oAttachment in Human Behavior (New York, Basic

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Attachment Among Aca