Measuring Attachment Security in Patients With Advanced Cancer

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attachment anxiety and avoidance have been foundto be associated with less social support and morepsychological distress [9].

The goals of the present analyses were to reporton (1) the psychometric properties of a modifiedversion of the 36-item Experiences in Close

Relationships [4] scale (ECR) for assessing attach-ment orientations (anxiety, avoidance) to closeothers, including both romantic and non-romanticrelationships; and (2) the construction of a brief version of our modified ECR for use in clinicalresearch. The short form may have greater utilitybecause it is less time-consuming and therefore lessburdensome for physically unwell individuals tocomplete.

The 36-item ECR [4] is a reliable and valid self-report measure of adult attachment that has beenused in hundreds of studies (see [3] for an extensive

review). The instrument asks individuals to reporton their thoughts, feelings, and experiences withromantic partners, and produces scores on thedimensions of anxious and avoidant attachment. Anumber of ECR items ask about experiences withmultiple romantic partners. This may be appro-priate for college-age samples, with whom thismeasure was developed and validated, and forwhom multiple dating partners may be common.However, such items may be less applicable toolder individuals who have been married orcommitted to the same person for many years.Although attachment orientations are highly re-levant in adult romantic relationships, the exclusivefocus of the ECR on tendencies in romanticrelationships may make it less valid for individualswho are not currently in a romantic relationship,who have had one longstanding relationship, orwho have had few total romantic relationships.

Given these considerations, in our research onpatients with advanced gastrointestinal (GI) or lungcancer, we modified the ECR (ECR-M36) to assessgeneral attachment orientations in close relation-ships, rather than in relation to romantic partners.This has allowed individuals with a wide range of

relational experiences, including those with few orlongstanding intimate relationships to complete theinstrument more easily. Considering attachmentorientations in non-romantic relationships duringthe course of severe or life-limiting illness is alsoconsistent with our interest in understanding theextent to which disturbances in relatedness to closefriends, family, and medical-care providers cancontribute to psychological distress [6]. Our mod-ified attachment measure may be particularlyappropriate to understand coping in medicalcontexts, where health outcomes are influenced by

the ability of individuals to seek out, trust, andinteract with the multiple persons involved in theircare [5]. We report here on the reliability andvalidity of this modified measure in a sample of advanced cancer patients near the end of life.

We also report on the construction andpsychometric properties of a 16-item brief formof our modified ECR (ECR-M16). To date, onlyWei and colleagues [10] have developed a brief ECR scale. They were able to shorten the ECR to12 items without unduly sacrificing reliability or

validity. However, their analyses were based on theoriginal items that assess romantic attachment andthe samples studied consisted of healthy under-graduate students. The present paper is thefirst to report on a brief measure of attachmentorientations to close others (including non-roman-tic partners), validated in a sample of adultmetastatic cancer patients with a broad rangeof ages.

The factor structure of the ECR scale

Brennan et al . [4] constructed the ECR scale from apool of 323 items gathered from numerousmeasures of romantic attachment orientations inuse at the time. They collected data from over 1000undergraduate students and calculated 60 subscalescores based on the items’ original scales. Anxiousand avoidant dimensions were then identified byfactor analysis. The ECR was created by selecting36 items (18 tapping each dimension) from the totalpool of items, based on the magnitude of theircorrelations with the two dimensions. In theirreport, Brennan et al . [4] focused on the factoranalysis of the subscale scores, rather than of theindividual items, although the results of bothanalyses were reported. It is important to notethat when factored at the item level, a higher-orderfactor structure was apparent: 12 first-order factorswere initially extracted from the 323 items; whenthese 12 factors were subsequently factored, twohigher-order dimensions emerged, which alsocorresponded to anxious and avoidant attachment[4, p. 66].

Subsequent psychometric studies have notfurther demonstrated a higher-order factor struc-ture in the ECR or its variations [10–14]. The most

relevant findings come from Wei et al . [10, study 1]who extracted two factors from the 18 avoidanceitems; a separate factor analysis of the 18 anxietyitems yielded three factors. The presence of multi-ple factors within the anxiety and avoidancesubscales is consistent with a higher-order factorstructure. In the present paper, we explicitly test fora higher-order structure, since a brief measureshould ideally be constructed so that it reproducesthe factor structure of the full measure.

Main hypotheses

We hypothesized that exploratory and confirma-tory factor analyses (CFAs) would show that theECR-M36 and ECR-M16 possess a higher-orderfactor structure. We also expected that the scales

Copyrightr 2008 John Wiley & Sons, Ltd. Psycho-Oncology 18 : 490–499 (2009)

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would demonstrate internal reliability (internalconsistency), test–retest reliability (temporal stabi-lity), and construct validity across different mea-surement occasions. To demonstrate constructvalidity, attachment anxiety and avoidance wereexpected to correlate negatively with self-esteem.This hypothesis was based on the theoreticalassumption that negative relational histories fostera negative view of self [15] and on empiricalfindings showing that attachment insecurities areassociated with low self-worth (see [3, Chapter 6]for an extensive review). Attachment anxiety andavoidance were also expected to correlate: (1)negatively with perceived social support, becauseinsecurely attached individuals, by definition,experience more difficulty in social relations withothers [3]; and (2) positively with depressivesymptoms, because insecurely attached individualsare less able to protect themselves from the stress of illness by the expectation or experience of support[5,6,9].

Method

Construction of the ECR-M36

We modified the 36-item ECR [4] to assessattachment to close others rather than to romanticpartners only. This was accomplished by substitut-ing, within relevant items, the terms ‘other people’or ‘people with whom I feel close’ in place of ‘romantic partner(s)’; and by adding the instruc-tion that the term ‘other people’ refers to peoplewith whom the patient feels close. As in the original

ECR, participants use a 7-point scale (1 ‘disagreestrongly’, 7 ‘agree strongly’) to rate their agreementwith statements based on their experiences in closerelationships. Anxiety and avoidance scores arecomputed by reverse-scoring and averaging rele-

vant items on each subscale. Higher anxiety andavoidance scores represent greater attachmentinsecurities. Time 1 internal reliabilities for theanxiety and avoidance subscales were high, Cron-bach’s alpha50.91 and 0.88, respectively. Time 2internal reliabilities were the same as Time 1

internal reliabilities.

Participants and procedure

The present study is a secondary analysis of theWill to Live (WTL) study [16], a longitudinalinvestigation of the determinants of psychologicaldistress in patients with advanced incurable cancer.The WTL protocol was approved by the UniversityHealth Network Research Ethics Board. Partici-pants were recruited from oncology outpatientclinics at Princess Margaret Hospital in Toronto,

Canada. Patients were eligible for the study if theywere 18 years of age or older; were sufficientlyfluent in English to give informed consent andcomplete self-report questionnaires; and werediagnosed with Stage IV GI or Stage IIIA, IIIB,or IV lung cancer.

Exclusion criteria included a diagnosis of carci-noid or neuroendocrine carcinoma, because of theunusual symptoms associated with those cancers;and cognitive impairment documented in themedical chart, identified by their physician, ordemonstrated by a failure to meet the cut-off scoreof 20 on the Short Orientation Memory Concen-tration Test [17] during recruitment. After provid-ing informed consent, patients were given aquestionnaire package to complete in the waitingroom or at home. Participants were assessedapproximately every 2 months until death or studywithdrawal.

The present study analyzed data from the Time 1or baseline assessment, completed at study entry,and the assessment that occurred between 4 and 6months after baseline, which will be referred to asthe Time 2 assessment. It was on these twooccasions that the ECR-M36 was administered to

participants. Because we were interested in thepsychometrics of the ECR-M36, we only analyzeddata from individuals who provided completeECR-M36 data. These patients did not differ fromnon-completers of the ECR-M36 on any othermeasured demographic, psychosocial, or disease-related variable. At Time 1, 309 individuals, out of the 419 who returned an assessment, providedcomplete ECR-M36 data. At Time 2, 120 indivi-duals, out of the 185 who returned an assessment,provided complete ECR-M36 data. In total, 97individuals provided complete ECR-M36 data at

both times (see Table 1 for sample characteristics).It is important to note that different statisticalanalyses focused on different time points, and thesample sizes therefore varied across analyses. Forexample, factor analyses of Time 1 data were

Table 1. Sample characteristics of individuals providing Time 1data, Time 2 data, and data at both times

Time 1 Time 2 Both times

n 309 120 97

M age 60.7 60.9 59.1

(SD age) (11.3) (11.8) (11.9)Female 41% 36% 33%

Married/ 73% 73% 78%

common law

More than 67% 67% 71%

high school education

Major types of cancer

Colorectal 37% 42% 40%

Lung 30% 30% 30%

Pancreas 14% 8% 14%

Hepatobiliary 13% 17% 13%

Because only the major types of cancer are listed, those percentages do not sum

to 100%.

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performed on the sample of 309 participants; factoranalyses of Time 2 data were performed on thesample of 120 participants; and analyses of cross-time correlations (e.g. test–retest reliabilities) wereperformed on the 97 participants who provideddata at both time points.

Other measures

Self-esteem was assessed using the 10-item Rosen-berg Self-Esteem Scale [18] (RSES). Higher scoresindicate higher self-esteem. Internal reliability of this scale was high in the current study, Cronbach’salpha5 0.88 at both times. Perceived social supportwas assessed using the Medical Outcomes StudySocial Support Survey [19] (MOS-SSS), a 20-itemscale that asks individuals to rate how much socialsupport they receive across multiple domains.

Higher scores indicate greater perceived socialsupport. Internal reliability was high, Cronbach’salpha5 0.96 at both times. Depressive symptomswere assessed using the Beck Depression Inventor-y–II [20] (BDI-II). The BDI-II is a 21-item self-report measure of depressive symptoms that isconsistent with the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, TextRevision [21] criteria for major depressive disorder.Higher scores indicate more severe depressivesymptoms. Internal reliability was high, Cron-bach’s alpha5 0.90 at Time 1 and 0.89 at Time 2.For more information about these measures in theWTL study (e.g. detailed descriptive statistics,imputation of missing values), see Rodin et al . [16].

Statistical analyses

Analyses were computed with SAS 9.1. To initiallyexamine the factor structure of the ECR-M36, aCFA was run on Time 1 data. The CFA tested thefit of a two-factor model in which the 18 itemsdesigned to assess attachment anxiety were indica-tors of one factor and the 18 items designed toassess avoidance were indicators of the other

factor. A good fitting model is indicated by aComparative Fit Index (CFI) greater than 0.90[22], a Non-Normed Fit Index (NNFI) above 0.90[22], and a Root Mean Square Error of Approx-imation (RMSEA) below 0.06 [23]. We predictedthat the two-factor model would not fit well if thedata possessed a higher-order factor structure.

Next, a higher-order factor analysis [24–27] wasconducted on Time 1 ECR-M36 data. Theprocedure began with an exploratory factor analy-sis with promax rotation to allow the first-orderfactors to be correlated. After extracting four first-

order factors, we then factor analyzed the inter-factor correlation matrix to yield the second-orderfactors. The second-order factors were varimax-rotated, rather than promax-rotated, to end thehigher-order factoring procedure.

When interpreting the meaning of the second-order factors, Gorsuch [25] advises against exam-ining the first-order factor loadings on the second-order factors. The reason is that to interpret thesecond-order factors based on their relation tointerpretations of the first-order factors would

amount to ‘basing interpretations upon interpreta-tions of interpretations’ [25, p. 245]. The solution isto post-multiply the first-order factor patternmatrix by the second-order factor pattern matrix,producing a product matrix which is then ortho-gonally rotated (see [26] for SAS programmingcode). This rotated product matrix constitutes theloadings of the original items on the second-orderfactors, and is used to interpret the meaning of thesecond-order factors. Although we had no predic-tions about the first-order factors that wouldemerge from the higher-order factor analysis, we

predicted that two second-order factors corre-sponding to attachment anxiety and avoidancewould emerge. Note that in our analyses, we didnot specify a single higher-order attachmentsecurity factor because attachment anxiety andavoidance have been conceptualized and empiri-cally demonstrated to be distinct behavioralstrategies that elicit different emotional and rela-tional consequences [3,4,10–15].

The items that were the best indicators of higher-order anxiety and avoidance and of the lower-orderfactors, as established at Time 1, were selected toform a brief measure. A CFA then tested thepresence of a higher-order factor structure in thereduced set of items, based on Time 2 data. Forcomparison, a second CFA also tested the presenceof a simple two-factor model (consisting of ananxiety factor and an avoidance factor) in thereduced set of items at Time 2. We predicted thatthe higher-order model would fit Time 2 data well,whereas the two-factor model would not.

Lastly, we examined the reliability and validityof the brief anxiety and avoidance subscales.Internal reliabilities at Time 1 and Time 2 andtest–retest reliabilities were calculated for the brief

subscales. Construct validity was examined usingthe correlations between attachment insecurities(anxiety, avoidance), and self-esteem, perceivedsocial support, and depressive symptoms. Higheranxiety and avoidance were predicted to correlatenegatively with self-esteem and social support, andpositively with depressive symptoms.

Results

CFA at Time 1

A CFA tested the fit of a two-factor model to theECR-M36 data at Time 1. The 18 items designed toassess attachment anxiety were specified as indica-tors of one factor; the 18 items designed to assess



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avoidance were specified as indicators of the second

factor; and the factors were allowed to correlate.As predicted, the two-factor solution fit poorly,CFI5 0.76, NNFI5 0.74, RMSEA5 0.077, indi-cating that there is more item variation than can beexplained by a simple two-factor structure. Thefactors were correlated at 0.45.

Exploratory higher-order factor analysis at Time 1

Four correlated factors were initially extracted byexploratory factor analysis of the 36 items, basedon the eigenvalue41 criterion and scree plot

examination [22]. The four factors explained 90%of the total variance. The variance explained byeach factor, controlling for the other factors, was18, 16, 14, and 9%, respectively. The first-orderfactor pattern matrix is shown in Table 2. Most of

the anxiety items loaded highly on Factor 1, which

we labeled as Frustration about Unavailability,because the highest loadings were associated withitems about the experience of frustration and upsetwhen close others are not available for support.Factor 2 consisted of half the avoidance items andwas labeled as Discomfort with Closeness, becausethe highest loadings were associated with itemsrepresenting discomfort with intimacy and a desireto pull away from others. Factor 3 consisted of thereverse-scored avoidance items and was labeledTurning Away from Others, because the highestloadings were associated with items assessing the

(lack of) willingness to disclose and rely on othersin times of need. Lastly, Factor 4 was labeled asWorrying about Relationships and consisted of asubset of anxiety items about relational worries(e.g. rejection, separation, abandonment).

Table 2. Time 1 item loadings on first-order factors

ItemsLoadings

F1 F2 F3 F4

30. I get frustrated when other people are not around as much as I would like 0.84 0.18 0.09 0.01

32. I get frustrated if other people are not available when I need them 0.83 0.13 0.05 0.10

36. I resent it when people with whom I feel close spend time away from me 0.68 0.02 0.03 0.03

24. If I can’t get other people to show interest in me, I get upset or angry 0.58 0.01 0.02 0.04

28. When I’m not involved in a relationship, I feel somewhat anxious and insecure 0.53 0.09 0.06 0.11

20. Sometimes I feel that I force other people to show more feeling, more commitment 0.50 0.09 0.05 0.12

34. When other people disapprove of me, I feel really bad about myself 0.46 0.13 0.02 0.02

18. I need a lot of reassurance that I am loved by people with whom I feel close 0.45 0.00 0.02 0.31

12. I often want to merge completely with other people, and this sometimes scares them away 0.45 0.24 0.19 0.13

26. I fi nd that other peopl e don’t want to get as cl ose as I woul d like 0.43 0.31 0.02 0.09

16. My desire to be very close sometimes scares people away 0.40 0.25 0.11 0.14

7. I get uncomfortable when other people want to be very close to me 0.08 0.76 0.01 0.01

13. I am nervous when other people get too close to me 0.17 0.75 0.05 0.12

17. I try to avoid getting too close to other people 0.14 0.71 0.16 0.14

23. I prefer not to be too close to other people 0.11 0.64 0.18 0.18

9. I don’t feel comfortable opening up to other people 0.00 0.63 0.18 0.05

5. Just when other people start to get close to me I find myself pulling away

0.12 0.63 0.06 0.26

11. I want to get close to other people, but I keep pulling back 0.17 0.61 0.04 0.10

1. I prefer not to show other people how I feel deep down 0.12 0.43 0.20 0.06

31. I don’t mind asking other people for comfort, advice, or helpa 0.11 0.02 0.66 0.22

27. I usually discuss my problems and concerns with people with whom I feel close a 0.16 0.04 0.65 0.03

33. It helps to turn to other people in times of needa 0.07 0.03 0.62 0.07

35. I turn to other people for many things, including comfort and reassurancea 0.07 0.04 0.61 0.00

25. I tell people with whom I feel close just about everything a 0.02 0.10 0.59 0.05

15. I feel comfortable sharing my private thoughts and feelings with other people a 0.12 0.13 0.51 0.05

19. I find it relatively easy to get close to other people a 0.03 0.15 0.47 0.08

3. I am very comfortable being close to other people a 0.10 0.21 0.40 0.07

2. I worry about being abandoned 0.06 0.02 0.01 0.68

8. I worry a fair amount about losing people with whom I feel close 0.09 0.11 0.03 0.59

4. I worry a lot about my relationships 0.28 0.01 0.03 0.52

6. I worry that other people won’t care about me as much as I care about them 0.21 0.32

0.06 0.4310. I of ten wish that other peopl e’s f eelings for me were as st rong as my f eelings for them 0.35 0.11 0.01 0.28

14. I worry about being alone 0.43 0.15 0.12 0.51

21. I find it difficult to allow myself to depend on other people 0.04 0.21 0.05 0.07

22. I do not often worry about being abandoneda 0.18 0.23 0.14 0.37

29. I feel comfortable depending on other peoplea 0.24 0.06 0.36 0.14

LoadingsX0.40 are in bold. The last five items listed did not loadX0.40 on any factor or loadedX0.40 on more than one factor. Highlighted items were selected for the

brief measure. F15 Factor 1, Frustration about Unavailability. F25 Factor 2, Discomfort with Closeness. F35 Factor 3, Turning Away from Others. F4 5 Factor 4,

Worrying about Relationships.aReverse-scored in the direction of anxiety or avoidance.

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possible to specify Discomfort with Closeness asbeing related only to Avoidance, nor was it possibleto freely estimate both paths without encounteringa negative variance parameter for Discomfort withCloseness in the CFA solution. The second CFAtested the 16 items for a simple two-factor solution

(i.e. the eight anxiety items specified as indicatorsof one factor, the eight avoidance items specified asindicators of the second factor, the factors wereallowed to correlate). The higher-order model waspredicted to fit better than the simple two-factormodel.

The higher-order model fit well at Time 2,CFI5 0.95, NNFI5 0.94, RMSEA5 0.056, andan examination of the modification indices andresidual covariance matrices did not reveal anyproblematic local item dependencies. The standar-dized parameter estimates are depicted in Figure 1.

Note that item 25 had a rather low path coefficient.

We tried replacing item 25 with item 35, the nextbest candidate, but the model fit was poorer and soitem 25 was kept. We also experimented withdifferent weighting schemes for the paths relatingDiscomfort to Avoidance and Anxiety (e.g. 0.6 toAvoidance and 0.4 to Anxiety), but these alternative

schemes yielded slightly poorer fitting models or anegative variance parameter for Discomfort. Final-ly, as predicted, the simple two-factor model fitpoorly, CFI5 0.79, NNFI5 0.75, RMSEA5 0.11,indicating that a higher-order factor structure isnecessary to account for the covariation amongitems.

Reliability and validity of the ECR-M16

Time 1 internal reliabilities were good for the brief anxiety and avoidance subscales, Cronbach’s al-

pha5

0.84 and 0.83, respectively, as were Time 2

Figure 1. Standardized parameter estimates for the confirmatory higher-order factor model at Time 2. D1-D4 are disturbanceterms. Error terms for items are not depicted

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internal reliabilities, Cronbach’s alphas5 0.86 and

0.81, respectively. The test–retest reliabilities werealso good for the brief and full subscales (seeTable 6 for these and other cross-time correla-tions).

Table 7 shows Pearson correlations between thefull and brief subscales within each assessmentoccasion. The full and brief anxiety subscalescorrelated highly at Time 1 and at Time 2, as wastrue of the brief and full avoidance subscales atboth times. Concerning construct validity, Table 7also describes Pearson correlations between theattachment subscales (full and brief) and self-esteem, perceived social support, and depressivesymptoms within each measurement occasion. Allsignificant correlations were in the predicteddirection. At Time 1, self-esteem showed a sig-nificant negative association with anxiety andavoidance. At Time 2, self-esteem showed asignificant negative association with avoidance.At Time 1 and at Time 2, anxiety and avoidanceshowed significant negative associations with socialsupport and significant positive associations withdepressive symptoms. See Appendix A for theECR-M16.

Discussion

We have reported on the psychometrics of amodified version of the 36-item ECR (ECR-M36)for measuring attachment orientations to closeothers (including non-romantic partners) in pa-tients with advanced incurable cancer. We havealso constructed a reliable and valid 16-itemversion of the modified ECR (ECR-M16) tofacilitate the study of attachment in medically illpopulations.

A higher-order factor structure was identified inthe ECR-M36 at Time 1, and was replicated in theECR-M16 at Time 2. This higher-order structure isconsistent with the factor structure of the 323 itemsout of which the original ECR was constructed [4,

p. 66]. In the present study, we found four first-order factors, representing Frustration about Un-availability, Worrying about Relationships, Discom-

fort with Closeness, and Turning Away from Others.We note that the Turning Away factor wascomposed of the positively keyed items of theavoidance subscale. Such clustering is common inself-report scales [28], and it is a limitation of theECR that its subscales do not have a balancednumber of positively keyed and negatively keyeditems. A factor analysis of the four first-orderfactors revealed two second-order factors identifiedas Attachment Anxiety and Avoidance, given thatitems meant to assess anxiety loaded on Anxietyand items meant to measure avoidance loaded onAvoidance.

Of theoretical importance is the finding that thefirst-order factor Discomfort with Closeness wasrelated to both Anxiety and Avoidance. The reasons

behind the ‘double-loading’ of Discomfort wereinitially unclear, based on Time 1 analyses. Of thethree items that make up the Discomfort factor,three items were found to load highly (i.e. X0.40)on both Anxiety and Avoidance. It was thereforepossible that the double-loading of Discomfort wasdue to just those three items. When selecting the 16items for the Time 2 factor analyses, we werecareful to choose items that did not double-load onboth Anxiety and Avoidance. The four selectedDiscomfort items loaded highly on only Avoidance,although we acknowledge that their loadings on

Anxiety are not inconsequential, ranging from 0.26to 0.36. Despite the removal of the three proble-matic items, it was evident from the Time 2 CFAthat Discomfort with Closeness still should bespecified as related to both Anxiety and Avoidance.

Table 6. Correlations across time for the full and brief attachment subscales

Time Scale T2 T2

Anx-18 Avo-18

T1 Anx-18 0.81 0.32

T1 Avo-18 0.28

0.76

T2 T2

Anx-8 Avo-8

T1 Anx-8 0.82 0.28

T1 Avo-8 0.26 0.73

Test–retest reliabilities are in bold. T15Time 1. T25Time 2. Anx-185 18-item

anxiety subscale. Avo-185 18-item avoidance subscale. Anx-85 8-item anxiety

subscale. Avo-85 8-item avoidance subscale.po0.05; ** po0.0001.

Table 7. Correlations between the full and brief attachmentsubscales, self-esteem, social support and depressive symptomsat Time 1 and Time 2

Time 1

Anx-18 Avo-18

Anx-8 0.96 0.32

Avo-8 0.29

0.94

Anx-8 Avo-8

RSES 0.36 0.33 0.36 0.33

MOS-SSS 0.35 0.42 0.34 0.40

BDI-II 0.43 0.21 0.42 0.19

Time 2

Anx-18 Avo-18

Anx-8 0.95 0.46

Avo-8 0.41 0.94

Anx-8 Avo-8

RSES 0.16 0.29 0.15 0.25

MOS-SSS 0.25 0.56 0.28 0.55

BDI-II 0.21 0.31 0.18 0.25

Anx-185 18-item anxiety subscale. Avo-18518-item avoidance subscale. Anx-

85 8-item anxiety subscale. Avo-85 8-item avoidance subscale. RSES5 self-

esteem. MOS-SSS5 social support. BDI-II5 depressive symptoms.po0.05; ** po0.0001.



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