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1. 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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2. 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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3. 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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4. 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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5. 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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6. 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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7. 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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8. 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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9. 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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10. 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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11. 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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12. 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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13. (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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14. 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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15. 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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16. 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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17. 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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18. 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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