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Addiction trajectory of how the infant will

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Addiction is a widely
used term for countless behaviors, ranging from the misuse of substances such
as alcohol and drugs, to the lesser acknowledged compulsive behaviors such as
sexual deviance and addictive relationships. Over the years, with the rise of
addiction rates, practitioners, researchers, and policy-makers have proposed a
myriad of different theories in approaching addiction, not limited to the
disease model, the biopsychosocial approach, and any and all psychological
theories (Cognitive-Behavioral, Psychodynamic, Person-Centered, etc.). This
paper aims to summarize literature on addiction as seen through the lens of
attachment theory and attachment styles. First, it will briefly present
attachment theory in the context of both infants and adults, highlighting how
this theory may be used to understand addiction. Next, it will discuss the recent
findings in empirical literature on the etiology of addiction and treatment
implications. Finally, this paper will conclude with a discussion on the gaps
in research and possible future directions of this approach.

 

Attachment
Theory

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             Parting from the prominent psychodynamic
theories of understanding psychopathology as a conflict of impulses primarily
rooted in fantasy, John Bowlby (1979) conceptualized a biological framework,
asserting that attachment is not formed as a function of physical needs being
met, but more so as its own function rooted in human biology. Previous
understanding of parent-child interactions implied that infants sought out a
relationship to their caregiver solely due to physical needs, such as being
fed; Bowlby presented an idea that drastically changed the way we understand
these relationships. Similar findings were demonstrated via Harry Harlow’s
(1958) study, looking at young monkeys. He found that infant monkeys cling to a
cloth figure, rather than a wire figure that has a bottle. In the medical
field, René Spitz (1945) found that infants who were provided for physically
but lacked human interaction had a significantly higher death rate than those
who had both. Research has consistently shown that human interaction and
interpersonal relationships are critical to human growth and development, in
more ways than one.

            According
to Bowlby, based on these early relationships with caregivers, infants begin to
learn what they can expect in their primary relationships. This is based on the
infant’s judgment of how dependable and responsive the attachment figure
(caregiver) is, as well as their judgment on the worth of self as an object. Once
a pattern emerges, an internal working model is created, which in turn, creates
a trajectory of how the infant will think, feel, and behave in any significant
relationships in the future. Mary Ainsworth’s (1969) famous study of the
Strange Situation identified four major classifications of attachment developed
within the infant’s first year. Secure attachment, which is considered the
healthiest, exists when infants feel they can rely on their attachment figure
to attend to their needs of proximity, emotional support, and overall
protection. Anxious-ambivalent attachment exists when infants feel separation
anxiety after separation from the attachment figure and do not feel reassured
even when the attachment figure returns. Anxious-avoidant attachment exists
when infants show little distress after separation from the attachment figure
and go on to avoid contact once the attachment figure returns. Disorganized
attachment exists when there is a general lack of a pattern of attachment
behavior.

            It
was not until the 1980s that Cindy Hazan and Phillip Shaver (1987) applied
attachment theory to adult relationships. Noticing that interactions between
adults share similarities to interactions between infants and caregivers, they
identified matching styles of attachment: secure, anxious-preoccupied,
dismissive-avoidant, and fearful-avoidant. Secure attachment implies ease in
becoming emotionally close with someone, greater satisfaction and adjustment in
relationships, and comfort with intimacy and independence. Anxious-preoccupied
attachment implies seeking high levels of intimacy and approval, yet as a
result, becoming overly dependent or preoccupied with the attachment figure. Dismissive-avoidant
attachment implies a desire for independence that leads to avoidance, a denial
in need for any close relationships, and an almost stubborn and defensive
stance toward attachment. Fearful-avoidant attachment implies mixed feeling
about close relationships, both a desire to be emotionally close and a fearful
discomfort with getting hurt. This application of attachment theory was
critical not only in the way it demonstrated the impact of childhood attachment
patterns, but also in the way it presented an alternative way of looking at
attachment in general, as an ongoing process that may prove to be extremely
relevant in understanding pathology in adulthood.  

 

Addiction
and Attachment

            In
recent years, much work has been conducted in the conceptualization and
treatment of addiction from the perspective of attachment theory. Theorists
such as Philip Flores (2004) asserted that since Bowlby claimed that secure
attachment are necessary for human affect regulation, it is possible that
adults with insecure attachment will specifically have problems with affect
regulation. In turn, the combination of unregulated affect and the inability to
turn to relationships can ultimately result in a pursuit of external sources of
regulation, such as substances, sex, gambling, etc. Fonagy et al. (2002)
similarly proposed that the way people’s attachment system is organized
corresponds with their capacity and style of relating to others.

Indeed, even anecdotal
evidence has demonstrated that those living with addiction often have issues in
interpersonal relations. The basis of this is seen even in the earliest
concepts of drug treatment, such as the infamous Alcoholics Anonymous quote, “Addicts
don’t have relationships; they take hostages!” (Taub, 2011). One of the most
paradoxical aspects of the understanding that addiction is an attempt to
regulate affect due to insecure attachment is that addiction has potential to
further reinforce the relationship problems already existing in the addicted
person. One of the many reasons working with addiction is so difficult is
perhaps because practitioners are faced with a behavior, a force, that is
consistently reinforcing the underlying relational issues and undermining the
practitioner’s efforts to help the patient attain a balance of intimacy and
autonomy.

 

Empirical
Findings

There is a growing body
of research on the relationship of attachment with psychotherapy, and while
this paper will mention the implications of attachment styles on psychotherapy,
it is more concerned with the etiology of addiction as it relates to
attachment.

Brook et al. (1990)
found that parent-child secure attachment in adolescents served as a protective
factor and offset risk factors such as peer drug use and the development of a
more serious substance use disorder. There have been even more studies looking
at adult attachment styles relating to substance abuse. Findings show that
adults who exhibit higher levels of insecure attachment in their romantic
relationships have a higher tendency to abuse substances (Kassel, Wardle, &
Roberts, 2006; Borhani, 2013).

There are few studies
on behavioral addictions and attachment style; however, one cyberpsychology
study in Taiwan also identified insecure attachment patterns as a risk factor for
internet addiction (Lin, Ko, & Wu, 2011). Also attempting to understand how
online communication may be related to attachment styles, Oldmeadow, Quinn, and
Kowert (2013) found that individuals with a more preoccupied or anxious attachment
style used Facebook, a social media website, more frequently and were more
concerned about how they were perceived via Facebook. The individuals with the
more avoidant style of attachment used Facebook less and also shared less
positive attitudes toward Facebook.

In terms of sexual
behaviors, Zapf, Greiner, and Carroll (2008) found that sexually addicted men
were found to have higher anxiety and avoidance in their romantic
relationships, signifying an insecure attachment to their partner.

A recent study by
Molnar et al. (2010) explored a dual-path model of high-risk drinking to assess
the relationship between attachment style and motivation for drinking. While
they did find that adults with insecure attachment were more likely to
participate in high-risk drinking, they also found that those who were more
avoidant had low scores in social motivation for their drinking. On the other
hand, those who were less avoidant and more preoccupied had significantly
higher scores in social motivation for drinking. This fits into the model of
adult attachment, considering that the anxious-preoccupied attachment pattern
is more concerned about social approval and sense of worth.

Using primarily the
ideas of Fonagy et al. (2002), De Rick, Vanheule, & Verhaeghe (2009)
identified 3 different subgroups of people with an alcohol use disorder in an
inpatient setting:

“A group with an
impaired attachment system manifesting itself in the incapacity

to develop secure
interpersonal relationships and problems with affect regulation (group

1), a group with a
well-established attachment system characterized by the ability to form

secure relationships
and the capacity for affect regulation (group 3), and a group with a

moderately functioning
representational system with either difficulties in affect regulation or in
interpersonal functioning (group 2).” (p. 105).

            The
authors found that the majority (52%) of their numerous samples in the
inpatient setting fell into the first group, exhibiting insecure attachment
styles. They also attributed their findings to the alcohol abusers’ lag in
self-development and affect regulation.

In summary, the general
consensus among the literature is that insecure attachment style seems to be a
factor in addiction, specifically in substance abuse, though the minimal
research in behavioral addictions supports that hypothesis as well. This has a
large impact on the field of addiction, not only in terms of how we can
conceptualize the etiology of addiction, but how we can address it in treatment
as well.

 

Treatment
Implications

De Rick and Vanheule
(2007) assert that it is crucial to differentiate patients on the basis of
attachment patterns, as it can have a dramatic impact on treatment process and
outcome. The general belief is that individuals with insecure attachment
patterns may not do as well in treatment, due to the highly
relationship-oriented process of psychotherapy, so the aim of therapy from the
perspective of attachment theory is to provide a corrective relational
experience that would modify the patient’s internal working model and allow
guidance for other close relationships. This approach is reminiscent of psychodynamic
psychotherapy in the way it creates an opportunity for the patient to
experience a secure attachment figure, who is responsive to the affective needs
of the patient.

Flores (2001), a leader
in the field, emphasizes the importance of group psychotherapy and the encouragement
of the addicted individual to establish and maintain healthy relationships
within the group, fostering autonomy, trust, and intimacy. Individual
psychotherapy can often be overwhelming, which is why he also recommends
self-help groups; the fellowship that arises from groups such as Sex and Love
Addicts Anonymous have potential to override the original attachment patterns.
Authors Ball and Legow (1996) also presented an excellent addiction treatment
model based in attachment theory, illustrating how the psychotherapist can
first establish a secure base and then shift to a phase of exploration within
the psychotherapy process.

The literature in
attachment theory rarely differentiates between behavioral and substance
addictions; while this may be due to the significantly larger amount of data
available for substance use disorders, it may also signify similar approaches
being used regardless of type of addiction. For example, Zapf, Greiner, and
Caroll (2008), despite studying sex addiction, made similar treatment
recommendations, including focusing on relational dynamics and addressing
insecurity in adult relationships.  

 

Future
Directions

            Though
addiction has been viewed by many as an attachment disorder, there are still
gaps in the empirical research. Theorists have been primarily focusing on the
affect regulation characteristic of secure attachment style; however, there
could be other factors relating to the insecure attachment patterns that may
put someone at higher risk for developing an addiction. As always with
developmental topics, more longitudinal studies across a lifespan would be
beneficial in helping understand how attachment directly impacts the
development and course of an addiction. Thorberg and Lyvers (2006), for
example, suggested that though insecure attachment could be a risk factor for
the development of a substance use disorder, it is also possible that insecure
attachment could be a consequence of
chronic substance abuse.  

            Molnar
et al. (2010) provided a fascinating dual-path to viewing substance use;
however, their study leads to the question of how social concerns, in relation
to attachment type, play into other forms of addiction, such as sex, internet,
or even eating disorders?

            Further
research in treatment can build on the models mentioned above or develop new
ones; one area of interest is how addressing attachment patterns may look
differently within different models of psychotherapy. Another crucial question
is whether psychotherapy based in attachment theory can actually change attachment
patterns. Promising models were provided by Flores (2001) and Ball & Legow
(1996); however, the idea of whether attachment patterns can be altered in
adulthood and to what extent that can be done has been a large debate in the attachment
theorist and practitioner community.

 

            This
paper focused on addiction as it is seen through the lens of attachment theory.
First, it gave an overview of the history of attachment theory and how the
theory was sequentially applied to infants, adults, and then specifically to people
living with addiction. Then, this paper reviewed a number of empirical studies
showing that attachment patterns, both in infancy and adulthood, impact the
development and severity of addiction, specifically in the field of substance
abuse. The overall consensus among researchers in the field is that insecure
attachment patterns are significantly correlated with various aspects of
addiction, including being a risk factor for and a reinforcer during addiction.
Addiction treatment implications were briefly discussed, and some ideas on
future directions were provided. 

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