ADDICTION RESEARCH & THEORY, 2016VOL. 24, NO. 3, 248–260ht.docx

ADDICTION RESEARCH & THEORY, 2016
VOL. 24, NO. 3, 248–260
http://dx.doi.org/10.3109/16066359.2015.1119267
An empirical study of attachment dimensions and mood
disorders in inpatient
substance abuse clients: The mediating role of spirituality
Naelys Lunaa, Gail Hortona, David Newmanb and Tammy
Malloyc
aSocial Work, Florida Atlantic University, Boca Raton, FL,
USA; bCollege of Nursing, Florida Atlantic University, Boca
Raton, FL, USA;
cBehavioral Health of the Palm Beaches, North Palm Beach, FL,
USA
ABSTRACT
Adult attachment style has been related to both spirituality and
psychopathology. This study aimed
to test the possible mediating role of two dimensions of
spirituality (purpose and meaning in life
and perceived relationship with God/higher power) between two
attachment dimensions (anxiety
and avoidance) and three mood disorders (major depressive
disorder, dysthymia and bipolar). In
total, 305 clients receiving inpatient substance abuse treatment
completed a battery of self-report
questionnaires. Path analyses revealed negative associations
between the anxiety attachment and
all the mood disorders. No significant associations were found
for attachment avoidance and the

mood disorders. Results also indicated negative associations
between the two attachment
dimensions and purpose and meaning in life. Concerning the
perceived relationship with God/
higher power, attachment avoidance was the only dimension
that showed a significant negative
association. Mediating effects of meaning in life and the
perceived relationship with God/higher
power were found between both attachment dimensions and two
of the mood disorders: major
depressive disorder and dysthymia. Further analyses of the
mediating effects revealed that purpose
and meaning in life was the factor accounting for the mediating
effects. Clinical implications and
future direction for research were discussed.
ARTICLE HISTORY
Received 22 June 2015
Revised 5 November 2015
Accepted 9 November 2015
Published online
7 December 2015
KEYWORDS
Attachment dimensions;
spirituality; mediating effect;
depressive disorders; sub-
stance use disorders
Introduction
Research has established high comorbidity rates between
substance use disorders (SUDs) and mood disorders
(Brienza et al. 2000; Grant et al., 2004; Diaz et al. 2012).

Individuals who struggle with these comorbid disorders
are more likely to relapse once they experience depres-
sive symptoms (Miller et al. 1996; Strowig 2000). In
addition, the severity of the drug abuse has been shown
to be greater in the presence of co-occurring disorders
(Tate et al. 2004). Other researchers have indicated that
more frequent injection use, sustained drug use, and
higher rates of relapse are found among those individuals
who experience SUDs and mood disorders (Marlatt and
Gordon 1985; Stein et al. 2003).
Considering the pervasive effects of these co-occurring
disorders and the potential influence of mood state on
relapse risk (Strowig 2000; Stein et al. 2003), it is crucial
that research focus on protective factors that may buffer
these effects. This study focuses on two of these factors –
attachment and spirituality – that research has suggested
may be important in the treatment of individuals
struggling with substance abuse issues (Jarusiewics
2000; Flores 2003; Chen 2006; Diaz et al. 2011). This
study was designed to test whether two dimensions of
attachment (anxiety and avoidance) are related to three
different mood disorders: major depressive disorder,
bipolar disorder and dysthymia. In addition, this study
examined whether two dimensions of spirituality (exist-
ential well-being and religious well-being) mediated
expected relationships between attachment and depres-
sive symptomatology among a sample of inpatients in
treatment for substance use disorders. Before presenting
the results of the study, a brief explanation of the
attachment and spirituality dimensions are provided
along with literature reviews of how the dimensions are
related to mood disorder and to each other.
Attachment dimensions

According to Mikulincer and Shaver (2007), attachment
style consists of two dimensions – anxiety and avoidance.
These two dimensions translate into the four categories
of attachment proposed by Bartholomew and Horowitz
(1991) that include individuals with secure attachment
style (Secure) and those with insecure attachment styles
(Preoccupied, Dismissing and Fearful). Similar to
Mikulincer and Shaver’s (2007) dimensions,
Bartholomew and Horowitz’s model also consists of
CONTACT Dr. Naelys Luna [email protected] Social Work,
Florida Atlantic University, 777 Glades Road, Boca Raton, FL
33433, USA
� 2015 Taylor & Francis
two dimensions – Self and Others. The Self dimension
has to do with the individual’s sense of lovability and
worthiness and their consequent expectations concern-
ing the availability of others in times of need. The Other
model has to do with the individual’s comfort with being
in intimate relationships. Thus, Mikulincer and Shaver’s
anxious attachment (AX) and avoidant attachment (AV)
dimensions correspond with Bartholomew and
Horowitz’s dimensions of Self and Others, respectively.
From Mikulincer and Shaver’s (2007) perspective,
adults with low AX and low AV (Secure) tend to assume
that they are worthy of love and that their partner will be
available when needed. They are also relatively willing to
have mutually supportive intimate relationships with
others. In comparison, those with relatively high AX and
low AV (Preoccupied) tend to doubt that their partner
will be there when needed because they doubt their

lovability and worth. Therefore, they tend to actively
demand high levels of support from their intimate
relationships, yet expect abandonment. Adults with low
AX and high AV (Dismissing) tend to have considerable
self-confidence and feel very capable of taking care of
themselves. However, they may downplay the import-
ance of relationship with others, actively avoiding
supporting others and not allowing others to support
them. Individuals who manifest high levels of both AX
and AV (Fearful) tend to doubt their lovability and
worth and their partner’s availability (similar to the
Preoccupied style). However, rather than actively
demanding support, they tend to be passive. As they
tend to distrust others (like the Dismissing style), they
may be slow to enter into an emotionally close relation-
ship. However, because they are so afraid of being alone,
once they are in relationship, they tend to stay even in
the face of exploitation and abuse.
Attachment dimensions and mood disorder
Although research has documented the relationships
among attachment dimensions and depressive symp-
tomatology (Eng et al. 2001; Williams and Riskind 2001;
Rholes and Simpson 2004; McMahon et al. 2006), only a
few studies have examined these factors in individuals
with SUDs (Caspers et al. 2006; Thorberg and Lyvers
2006; De Rick et al. 2009; Diaz et al. 2014). For example,
Thorberg and Lyvers (2006) examined a group of 99
individuals attending substance abuse treatment and 59
non-clinical controls concerning their attachment style,
degree of fear in intimate situation and their differen-
tiation of self. They reported that the participants in
treatment indicated significantly higher levels of both
insecure attachment and fear of intimacy as well as lower
levels of self-differentiation when compared with the

non-clinical participants. Flores (2003) examined the
link between attachment style and depressive symptoms
among individuals with substance use disorders and
argued that inadequate, inconsistent and unreliable
parenting during infancy may contribute to impaired
emotional regulation among these individuals. These
individuals may attempt to cope with the impaired
emotional regulation by using substances that numb
their psychological distress and/or providing distractive
stimulation. He argued that substance use disorders are
‘both a consequence of and a solution to the absence of
satisfying relationships’ (Flores 2003, p. 50) in these
individuals’ lives.
Similarly, De Rick et al. (2009) explored the relation-
ships between alexithymia, psychiatric disorders and
attachment dimensions among 101 individuals attending
inpatient treatment for alcoholism. Findings revealed
that �86% of the entire sample reported insecure
attachment dimensions and difficulty regulating affect
and developing and maintaining interpersonal relation-
ship. Results also showed that three different subgroups
of clients can be distinguished according to their
attachment dimensions. The first group, which included
a little over half of the clients, exhibited an impaired
attachment system. These individuals had serious diffi-
culty regulating their emotions and establishing secure
interpersonal relationships. Another subgroup involving
over a third of the participants reported moderate
attachment impairment, whereby they showed difficulty
in either regulating their emotions or in establishing
relationships. The last subgroup, including about 14% of
the sample, involved individuals with secure attachment
systems who were able to regulate their affects and
establish good interpersonal relationships.

Finally, a recent study examined attachment style,
spirituality and depressive symptomatology among 77
clients attending a residential treatment facility (Diaz
et al. 2014). These authors reported that individuals with
insecure attachment style and lower levels of existential
purpose and meaning in life were more likely to have
higher levels of depression compared with individuals
with secure attachment style and high levels of purpose
and meaning.
Spirituality dimensions
The conceptualization of spirituality as being distinct
from religion has been a topic of debate among scholars
(Mohr 2006; Koenig 2008). Koenig (2008) presented the
evolution of the way spirituality has been defined over
several decades. Originally it was associated with faith
practices or religious individuals; however, as spirituality
has been examined in health and mental health research,
ADDICTION RESEARCH & THEORY 249
it has been expanded beyond religion to include values,
positive character traits and positive mental health states
(i.e. meaning in life, connections with others, peaceful-
ness, well-being, harmony and hope) (Koenig 2008).
Dalmida (2006) perceived spirituality as being a wider
construct than religion in that it involves a personal
relationship with a higher power. Similarly, Hood et al.
(2009, p. 289) held that ‘religious experiences constitute a
more restricted range than the diversity that character-
ises spiritual experiences’. Seidlitz et al. (2002) argued
that religion and spirituality are indeed similar in that

both involve a search for the sacred (a divine being or of
a sense of ultimate reality or truth). However, these
authors differentiated between the two by pointing out
that spirituality is concerned with an individual’s
personal search whereas religion is a group effort to
direct and to provide approval of that search.
Along the same lines, religion has been defined as an
organised system of beliefs manifested in rituals, values
and guidelines of conduct (Mohr 2006). These differen-
tiations seem to be consistent with Canda and Furman
(2010, p. 76) who have argued that religion is ‘an
institutionalized. . .pattern of values, beliefs, symbols,
behaviors and experiences’ associated with a particular
community that may include spirituality as one of its
defining features. Spirituality, on the other hand, both
includes and transcends religion. They define spirituality
as being ‘a universal quality of human beings and their
cultures related to the quest for meaning, purpose,
morality, transcendence, well-being and profound rela-
tionships with ourselves, others and ultimate reality’
(Canda and Furman 2010, p. 5).
Thus, it appears that spirituality is a multidimensional
construct that involves the search for individual meaning
and/or purpose in life and connectedness to oneself,
others and the transcendent (Diarmuid 1994; Seidlitz
et al. 2002; Canda and Furman 2010; Oman 2014). Cook
(2004) reviewed 265 books and articles regarding
spirituality and provided a comprehensive conceptual-
ization of the term. Cook stated that spirituality is ‘a
distinctive, potentially creative and universal dimension
of human experience’ (Cook 2004, p. 548) that may be
formed through the relationship with self, with others or
with that which is beyond the self. Spirituality is also
defined as an essential factor that provides purpose and

meaning to life (Cook 2004). The spirituality dimensions
of purpose and meaning and relationships with others
and the transcendent are also discussed in the work of
Canda and Furman (2010). It is the concepts of
existential well-being (purpose and meaning in life)
and religious well-being (relationship with God) that will
be examined in this study.
Spirituality and mood disorder
The literature on spirituality and depression has docu-
mented the protective value of spirituality for different
populations (Nelson et al. 2002; Doolittle and Farrell
2004; Hill et al. 2005; Sorajjakool et al. 2008).
Interestingly, research studies in this area seem to
focus on two components of spirituality: (1) spiritual
existential purpose and meaning in life and (2) religious
beliefs. For instance, in a qualitative study exploring the
role of spirituality and meaning in life among 15 clients
diagnosed with severe depression, Sorajjakool et al.
(2008) reported three themes of interest. First, the
authors indicated that depressed clients reported a lack
of spiritual connection evidenced by a disconnection
with God, the community in general and oneself. Clients
also reported that spirituality played an important role in
their struggles with depression, whereby they experi-
enced a deep yearning for a sense of meaning in their
lives trying to make sense of their pain and struggles with
depression.
Another study conducted by Hill et al. (2005)
examined spirituality and distress in palliative care and
concluded that those clients who expressed anger at God
or had negative religious coping skills were more
depressed. Similarly, Doolittle and Farrell (2004)
reported that, among urban clients, those who scored

higher on spiritual assessment have fewer depressive
symptoms. More specifically, those clients who had a
belief in a higher power, engaged in prayers and reported
having a relationship with a higher power experienced
lower levels of depression. Examining both spirituality
and religion and their relationship to depression among
162 terminally ill patients with cancer and AIDS, another
study reported a negative correlation between meaning
in life and peacefulness and depression (Nelson et al.
2002); however, no relationship was found between
religious well-being and depression among these
individuals.
Although the associations between spirituality and
depression have been examined in various clinical
populations yielding interesting results about the dis-
tinction of protective quality of different dimensions of
spirituality, recent research concerning spirituality as a
protective factor for individuals with depressive symp-
tomatology and SUDs is scant. In a substance abuse
sample, two important factors of spirituality, purpose
and meaning and the relationship with God, were
examined among 111 clients attending residential treat-
ment (Diaz et al. 2011). Findings indicated that the
existential dimension of spirituality (purpose and mean-
ing in life) showed a strong and inverse relationship with
depressive symptoms, whereas the relatedness to God
250 N. LUNA ET AL.
aspect showed a significant positive relationship with
depressive symptoms (Diaz et al. 2011). Other research
has also shown that spirituality is a key factor regarding
positive treatment outcomes and recovery for substance

use disorders (Jarusiewics 2000; Chen 2006). Spirituality
has been correlated to abstinence during or after
treatment (Jarusiewics 2000) and has been noted as ‘a
powerful antagonist of addiction’ (Unterrainer et al.
2012, p. 68).
Attachment, religion and spirituality
A considerable body of literature has arisen concerning
relationships between the religious aspect of spirituality
and attachment styles and dimensions (Kirkpatrick and
Shaver 1992; Kirkpatrick 1998; Grandqvist and Hagekull
2000; Byrd and Boe 2001; Eurelings-Bontekoe et al. 2005;
Hood et al. 2009). For example, researchers have found
that secure attachment was positively related to higher
levels of religiosity, more positive images of God and
perceptions of greater closeness to God than those
reported by individuals with insecure styles (Kirkpatrick
and Shaver 1992; Kirkpatrick 1998; Grandqvist and
Hagekull 2000; Byrd and Boe 2001; Eurelings-Bontekoe
et al. 2005).
Hood et al. (2009) have pointed out that the qualities
attributed to God (at least the God of Christian
traditions) tend to correspond closely to the attributes
associated with secure attachment figures in early
childhood. Similarly, Grandqvist et al. (2012) have
indicated (citing Kaufman 1981) that ‘The idea of God
is the idea of an absolutely adequate attachment figure’
(Grandqvist et al. 2012, p. 804) and have argued that, for
individuals who believe in a personal God, God can
provide a sense of ‘felt security’ and a ‘safe haven’ similar
to that provided by early attachment figures. They tested
the two pathways in a series of four experimental design
studies utilising a sample of adults in Israel and found
that individual differences in levels of attachment anxiety

and avoidance were related to individual differences in
attachment to and images of God. Those with more
secure adult attachment tended to have more secure
attachment to God, whereas those with more insecure
adult attachment tended to have more insecure attach-
ment to God that corresponded with their levels of
anxiety and avoidance in their close personal relation-
ships. In addition, they reported that God provided a safe
haven and secure base to their respondents that was
significantly reduced by the presence of insecure
attachment.
Although there are numerous studies of attachment
and religion as discussed above, only two studies in the
current literature have examined attachment and
spirituality (as opposed to religion/religiosity). In one
study, Horton et al. (2012) explored differences in
spirituality dimensions, religious background and God
images associated with adult attachment style using a
sample of individuals in residential treatment for sub-
stance use issues. They found that religious background,
God image and the religious well-being dimension of the
spirituality measures did not vary by attachment style.
However, the existential purpose and meaning dimen-
sion of spirituality did vary such that those with a secure
attachment style had significantly higher levels of
purpose and meaning in life than any of the insecure
attachment styles. In a later study, Diaz et al. (2014)
reported that whereas both attachment style and the
purpose/meaning dimension of spirituality were related
to depressive symptomatology, purpose/meaning was
the best predictor of depression level among individ-
uals attending a residential substance abuse treatment
facility.

Study rationale and hypotheses
As the literature review above shows, attachment and
spirituality dimensions are related to depressive symp-
toms. However, attachment dimensions also seem to be
related to spirituality among individuals with SUDs
whereby individuals with attachment avoidance/anxiety
appear to have less purpose and meaning in life than
individuals with secure attachment style (Horton et al.
2012). Is it possible, then, that the relationship between
attachment and depressive symptoms is mediated by
spirituality? Researchers are in agreement that, in
response to adaptive evolutionary forces that promote
survival, children start to form attachment bonds
starting at birth (Bowlby 1982; Mikulincer and Shaver
2007). By the age of six or seven months an attachment
style and an internal working model of self have begun to
develop and are solidly in place by the age of 2 years
(Mikulincer and Shaver 2007). The style is then very
likely to be carried forward through childhood and
adolescence into adulthood (Bartholomew and Horowitz
1991; Mikulincer and Shaver 2007).
Spirituality, on the other hand, is thought to begin to
develop at some point after infancy because children in
the sensorimotor stage are unable to differentiate self
from other or to experience an awareness of an abstract
such as God (Cartwright 2001). Hood et al. (2009)
argued that, based on Piaget’s understanding of cognitive
development, children are not capable of understanding
the complexities of adult religious thought until adoles-
cence. However, they also noted that there is consider-
able evidence for a genetic component to spirituality,
indicating a probability that humans are born with a

neurobiological system predisposed to religious/spiritual
thought. Indeed, Richert and Granqvist (2014, p. 170)
have argued that ‘the relationship with God develops in
temporal conjunction with the maturation of the
attachment system and the cognitive developments
associated with that maturation’.
It should be noted, however, that (as might be
expected given the methodological issues associated
with questioning very young and preverbal children)
none of the studies reviewed by Hood et al. (2009) or
Oman (2014) concerning religious/spiritual develop-
ment during childhood were conducted using a sample
of children under the age of 4 years. Therefore, very
little is known about the possible development of
spirituality in infancy and toddlerhood. However, as a
great deal is known about the development of attach-
ment during those developmental stages, we are
assuming that for the purposes of this study that
attachment precedes the development of spirituality.
Our purpose for this study was, therefore, to explore
the possibility that attachment may influence individ-
uals’ levels of existential purpose and meaning in life
and/or relatedness to God, which in turn influences
mood disorder. Specifically, this study aimed to explore:
(1) to what extent attachment dimensions directly
predicted different types of mood disorders including
major depressive disorder (MDD), bipolar disorder
(BIP) and dysthymia (DYS) among individuals attend-
ing substance abuse treatment and (2) whether the
relationships between attachment dimensions and
mood disorders were mediated by spirituality. Based
on the above reviewed literature, we hypothesised that

there would be a positive relationship between attach-
ment anxiety and all three mood disorders; we also
predicted a positive relationship between attachment
avoidance and the three mood disorders. The positive
effect of attachment dimensions on the mood disorders
was expected to be mediated by levels of purpose and
meaning in life. We anticipated that religious well-being
would not show a significant mediation effect between
the attachment dimensions and the three mood
disorders.
The findings from this research may increase our
understanding regarding the relative importance of
both attachment dimensions and spirituality and their
impact on depressive symptoms among individuals with
SUDs. These factors may contribute distinctively to the
development and severity of depression in this popu-
lation. Mental health professionals may then have a way
of identifying a focus of clinical attention for clients
with comorbid SUDs and mood disorders addressing
both their spirituality and their interpersonal
relationships.
Methods
Participants
Clients were recruited from a residential substance abuse
treatment center located in southeastern Florida after
receiving approval from the Institutional Review Board.
The treatment facility is a for-profit agency that uses the
12-steps model of Alcohol Anonymous (AA) to provide
a wide range of mental health services including
detoxification, inpatient, residential, partial hospitaliza-
tion and intensive outpatient. Attendance at this agency
is voluntary. Clients consented to participate in our

study after having completed the detoxification phase at
the facility and being deemed medically and psychiatric-
ally stable to move into a lower level of care. As part of
the facility’s regular procedure, staff met with each client
within 72 h of his or her discharge from detox. At that
time, staff conducted a psychosocial assessment evalu-
ation and asked the client to fill out a battery of
assessment tools to determine diagnosis and treatment.
Staff then informed the clients about the study, obtained
informed consent and asked the client to complete an
additional self-report survey measuring spiritual well-
being provided by the study researchers. Clients who
refused participation were excluded from the study. In
total, 305 clients were recruited over a period of 1 year
and agreed to participate in the study. The mean age of
participants was 33.7 years. Approximately 62% of
participants were male, and almost all were White
non-Hispanic (89%).
Measures
The Experiences in Close Relationships Scale-revised
The Experiences in Close Relationships Scale-revised
(ECR-R) (Fraley et al. 2000) is a 36-item self-report
scale used to assess adult romantic attachment style.
The ECR-R comprises two subscales (18 items each)
measuring AX (e.g. ‘I worry a lot about my relation-
ships’) and AV (e.g. ‘I find it difficult to allow myself to
depend on romantic partners’). Respondents are asked
how they feel in emotionally intimate relationships.
Each item is rated on a 7-point Likert scale ranging
from ‘completely agree’ to ‘completely disagree’. The
scales are almost uncorrelated (r¼0.11) with coefficient
alphas above 0.90 (Riggs et al. 2007). Other researchers
have documented high internal consistency, test–retest

reliability as well as construct, predictive and discrim-
inant validity (Crowell et al. 1999). For this sample,
Cronbach alphas were 0.89 for the attachment anxiety
and 0.90 for attachment avoidance.
252 N. LUNA ET AL.
The Spiritual Well Being Scale
The Spiritual Well Being Scale SWB (Ellison 1983) was
used to measure spirituality. This is a 20-item self-report
instrument that contains two subscales: (1) the
Existential Well Being subscale (EWB or ‘meaning’)
(e.g. ‘I don’t know who I am, where I came from, or
where I am going’) and (2) the Religious Well Being
subscale (RWB or ‘God/higher power’) (e.g. ‘I have a
personally meaningful relationship with God’). The SWB
has a 6-point Likert-type scale ranging from 1¼strongly
disagree, 2¼mostly agree, 3¼disagree, 4¼agree,
5¼moderately agree, and 6¼strongly agree. It has
demonstrated good psychometric properties. Coefficient
alphas of 0.97 and a test–retest coefficient of 0.93 have
been reported for the RWB, whereas the EWB obtained
0.90 and 0.80, respectively (Saunders et al. 2007).
Cronbach alphas for this sample were 0.92, 0.93 and
0.89 for the SWB, RWB and EWB, respectively.
The Millon Multixial Clinical Inventory-III
The Millon Multixial Clinical Inventory-III (MCMI-III)
(Millon et al. 2009) is the latest revision of this widely
used 175-item self-report questionnaire that consists of
28 scales: four scales measure the validity and response
style (validity index, disclosure, desirability and debase-

ment), 14 scales measure personality disorders and 10
scales measure clinical syndromes including dysthymia,
alcohol dependence and drug dependence. For the
purpose of this study, the MCMI was utilised to measure
mood disorder traits (dysthymia, major depressive
disorder and bipolar). This instrument has demonstrated
good psychometric properties (Millon 1997; Craig and
Olson 1998; Craig and Olson 2001), and has been used as
an assessment tool in several studies of individuals who
abuse drugs (Craig and Olson 1998; Calsyn et al. 2000;
Teplin et al. 2004; Diaz et al. 2009).
The MCMI-III scores the psychological traits and
symptoms as follows: (1) a score �85 is indicative of all
the traits and symptoms for a given mental disorder at a
clinical level; (2) scores between 75 and 85 indicate the
presence of traits and symptoms associated with the
disorder, below clinical levels and (3) a score 575 is
considered to lack clinical significance. For the purpose of
this study, three scales assessing the clinical syndromes of
mood (dysthymia, major depressive disorder and bipolar)
were utilized.
Data analyses
Correlation analyses were conducted to examine the
relationship between the independent (anxiety [AX] and
avoidance [AV] attachment dimensions), mediating
(existential purpose and meaning in life [EWB] and
religious well-being [RWB]) and dependent variables
(major depressive disorder [MDD], dysthymia [DYS]
and bipolar disorder [BIP]). Three separate path analysis
models using the AMOS software (Chicago, IL) were
used to examine the relationships between the two
independent variables, avoidant attachment styles (AV),

anxious attachment styles (AX), relationship with higher
power (RWB) and meaning and purpose in life (EWB)
on the three mood disorders in the study: MDD, DYS
and BIP. The primary endogenous variables in this study
were the three mood disorders. Both the RWB and EWB
were second level endogenous variables that mediated
the effects of attachment styles on the mood disorders of
MDD, DYS and BIP. The overall fit of these models were
assessed using chi-square, comparative fit index (CFI)
and overall R2. All of these indexes assess the
discrepancies between the data and the hypothesised
model. Both the CFI and R2 values range from 0 to 1
with higher score indicating better fit, whereas lower
score indicated less discrepancy for the chi-square.
Results
Correlation analyses
Table 1 presents the results of the correlation analyses
examining the relationships between the main variables
of the study. MDD showed significant and positive
correlations with DYS and BIP symptoms, both attach-
ment dimensions, and the RWB dimension of spiritu-
ality. In addition, there was a significant negative
correlation between MDD and the EWB dimension of
spirituality.
DYS showed a significant and positive correlation
with BIP and both attachment dimensions. However, in
contrast to MDD, DYS was significantly and negatively
correlated with both EWB and RWB. Unlike either
MDD or DYS, BIP showed a significant positive
correlation only with the AX attachment dimension.
Table 1. Correlations of mood disorders attachment dimensions

and spirituality subscales.
Variable Mean (SD) 1 2 3 4 5 6
1. MDD 64.63 (28.11) –
2. DYS 68.45 (26.23) 0.79
b
–
3. BIP 59.37 (20.83) 0.24b 0.308b –
4. AX 67.04 (16.49) 0.33b 0.412b 0.207b –
5. AV 53.20 (21.03) 0.29b 0.264b 0.03 0.349b –
6. RWB 38.30 (11.07) 0.18b �0.142a 0.10 �0.07 �0.155a –
7. EWB 39.97 (10.98) �0.489b �0.565b �0.03 �0.462b
�0.472b 0.396b
ap�0.05.
bp�0.01.
Finally, AX showed a significant positive correlation
with AV and a significant negative correlation with EWB
whereby AV showed a significant negative correlation
with both EWB and RWB.
Path model analyses
There were three distinct path analyses conducted to
investigate the relationships among attachment style
dimensions, the three mood disorders (MDD, DYS and
BIP) and the mediating effects of spirituality as measured
by RWB and EWB. Results indicated that the overall fit

of the models is generally adequate. The chi-square for
all three models is40.05; the CFI for DYS and MDD are
low but adequate with a CFI¼0.89 and 0.87, respect-
ively, and with a poor fit for BIP with a CFI¼0.82. The
overall R2 ranges from a high of 0.33 for DYS to a low of
0.07 for BIP. MDD fell in the middle with an R2¼0.23.
Figures 1, 2 and 3 show the results of the path model
analyses for MDD, DYS and BIP, respectively. In each
figure, the rectangles are observer variables where AV
and AX are exogenous variables and RWB and EWB,
acting as mediators, are both exogenous and endogenous
variables. The mood disorder (MDD, DYS or BIP) is the
outcome endogenous variable. To best reflect the rela-
tionship between the spirituality subscales, the error
terms for RWB and EWB were correlated. Individual
results for direct and mediating effects shown in the
three path model analyses are discussed below.
Major depressive disorder
Figure 1 and Table 2 show the results of the path analysis
for MDD. Results indicated that there was a significant
positive direct effect of AX on MDD (�¼0.14,
p¼0.02), but not a significant effect of AV on MDD
Figure 2. Attachment styles mediated by spirituality predicting
dysthymia.
MDD.
254 N. LUNA ET AL.

(�¼0.05, p¼0.35). AX had a significant negative direct
effect on EWB (�¼�0.36, p50.01) but was not
significant on RWB (�¼�0.04, p¼0.52). AV had
significant negative direct effects on both EWB
(�¼�0.37, p50.01) and RWB (�¼�0.15, p¼0.01).
RWB did not show a significant direct effect in
predicting MDD (�¼�0.01, p¼0.89) whereas EWB
had a significant direct effect (�¼�0.39, p50.01).
Regarding indirect effects, results indicated that there
were significant effects for both AX and AV as mediated
by RWB and EWB in predicting MDD (�¼0.14,
p¼0.02 and �¼0.14, p¼0.02, respectively).
Dysthymia
Figure 2 and Table 2 show the results of the path analysis
for DYS. Similar to MDD, there was a significant positive
direct effect of AX on DYS (�¼0.21, p5 0.01), but no
significant effect of AV on DYS (�¼�0.03, p¼0.53).
AX had a significant negative direct effect on EWB but
Table 2. Standardised path weights for direct, indirect and total
effect of the mood disorders.
Standardised effects
Direct Indirect Total
Dx Endogenous Exogenous Estimate S.E. p Value Estimate p
Value Estimate p Value
MDD RWB 5– Anxiety �0.04 0.04 0.517
EWB 5– Avoidance �0.37 0.03 50.001
EWB 5– Anxiety �0.36 0.03 50.001
RWB 5– Avoidance �0.15 0.03 0.012

MDD 5– RWB �0.01 0.14 0.888
MDD 5– EWB �0.39 0.17 50.001
MDD 5– Avoidance 0.05 0.08 0.345 0.14 0.016 0.2 50.001
MDD 5– Anxiety 0.14 0.1 0.016 0.14 0.016 0.28 50.001
Dysthymia RWB 5– Anxiety �0.03 0.04 0.582
EWB 5– Avoidance �0.37 0.03 50.001
EWB 5– Anxiety �0.35 0.03 50.001
RWB 5– Avoidance �0.16 0.03 0.009
Dysthymia 5– RWB 0.07 0.12 0.179
Dysthymia 5– EWB �0.5 0.15 50.001
Dysthymia 5– Avoidance �0.03 0.07 0.526 0.17 0.001 0.14
0.016
Dysthymia 5– Anxiety 0.21 0.08 50.001 0.17 0.001 0.38 50.001
Bipolar RWB 5– Anxiety �0.04 0.04 0.488
EWB 5– Avoidance �0.36 0.03 50.001
EWB 5– Anxiety �0.36 0.03 50.001
RWB 5– Avoidance �0.15 0.03 0.011
Bipolar 5– RWB 0.1 0.12 0.105
Bipolar 5– EWB 0.02 0.14 0.751
Bipolar 5– Avoidance �0.03 0.06 0.627 �0.02 0.75 �0.05
0.432
Bipolar 5– Anxiety 0.24 0.08 50.001 �0.01 0.853 0.23 50.001
bipolar.
was not significant on RWB (�¼�0.35, p50.01;
�¼�0.03, p¼0.58, respectively). AV had significant
negative direct effects on both EWB and RWB
(�¼�0.37, p50.01; �¼�0.16, p¼0.01, respectively).

RWB did not show a significant direct effect on DYS
(�¼�0.07, p¼0.18) whereas EWB had a significant
direct effect (�¼�0.50, p50.01). Results indicated that
there were significant indirect effects for both AX and
AV as mediated by RWB and EWB on DYS (�¼0.17,
p50.01 and �¼0.17, p50.01, respectively).
Bipolar disorder
Figure 3 and Table 2 show results of the path analysis for
BIP. Similar to MDD and DYS, there was a significant
positive direct effect of AX on BIP (�¼0.24, p5 0.01),
but no significant effect of AV on BIP (�¼�0.03,
p¼0.63). AX had a significant negative direct effect in
predicting EWB (�¼�0.36, p50.01) but was not
significant in predicting RWB (�¼�0.04, p¼0.49).
AV had significant negative direct effects in predicting
both EWB and RWB (�¼�0.36, p50.01; �¼�0.15,
p¼0.01, respectively). Unlike MDD and DYS, there
were no significant indirect effects for either AX or
AV as mediated by RWB and EWB in predicting
BIP (�¼�0.01, p¼0.75 and �¼�0.02, p¼0.85,
respectively).
Discussion
Recent research has shown that insecure adult attach-
ment styles are related to difficulty in regulating negative
mood among individuals with substance use issues
(Thorberg and Lyvers 2010). Other research has sug-
gested that the meaning and purpose dimension of
spirituality is positively related to depressive symptoms
in this same population (Diaz et al. 2011). However, this
study is the first to examine both of these factors
simultaneously in association with mood disorder. The
aim of this study was to examine the relationships

between attachment dimensions (anxiety and avoidance)
and three mood disorders (MDD, bipolar and dys-
thymia) among a clinical sample of individuals attending
substance abuse treatment, with special attention focused
on the possible mediating role of spirituality (existential
purpose and meaning, and religious well-being or
perceived relationship with God). The results will be
discussed separately for the direct effects of the attach-
ment dimensions on the mood disorders, and the direct
effects of the attachment dimensions on spirituality.
Then results for the mediating effects of the two
spirituality dimensions will be discussed.
Direct effects
Attachment dimensions and mood disorder
As hypothesised, attachment anxiety showed a direct
positive effect with all of the mood disorders. Those
individuals with a strong sense of lovability/worthiness
(low levels of the attachment anxiety) were more likely to
report low levels of the symptomatology for MDD,
dysthymia and bipolar. This finding is consistent with
previous research (Kassel et al. 2007) proposing that
people with anxious romantic attachment use substances
to decrease their negative feelings related to being
abandoned by others. Interestingly, attachment avoid-
ance was not significantly related to any of the mood
disorders. That is, individuals’ willingness to be intimate
with others and to develop trusting relationships did not
seem to be related to levels of depressive symptom-
atology in this sample.
Attachment dimensions and spiritual dimensions
In regard to the direct effect of the attachment dimen-

sions on the spirituality dimensions, we found that both
attachment anxiety and avoidance showed significant
negative direct effects on the purpose and meaning
dimension of spirituality for all the three mood dis-
orders. For all three moods disorders, the higher the level
of attachment anxiety, the lower the level of purpose and
meaning in life. That is, the more an individual was
afraid of being abandoned by their romantic relation-
ship, the less purpose and meaning he or she was
experiencing. The higher the level of attachment avoid-
ance, the lower the level of existential purpose and
meaning. It seems that the less interested an individual
was in sharing him or herself intimately with another,
the less purpose and meaning he or she was experien-
cing. There were no significant direct effects of attach-
ment anxiety on the religious dimension of spirituality.
An individual’s fear of being abandoned in his or her
current romantic relationship did not affect his or her
feelings of closeness with God. However, individuals
with higher levels of attachment avoidance tended to
have lower levels of religious well-being. That is, the less
likely an individual was in sharing him or herself
intimately with another, the less he or she was interested
in being close to God.
Mediating effects
When we examined the possible mediating role of the
spiritual dimensions on the relationships between
attachment dimensions and the three mood disorders,
we found that religious well-being did not significantly
256 N. LUNA ET AL.

mediate the relationship between either of the attach-
ment dimensions and any of the mood disorders. It
seems that the perceived relationship with God did not
affect the levels of mood disorder symptoms in this
sample. However, we did find that existential purpose
and meaning in life mediated the effect of both of the
attachment dimensions on MDD and dysthymia symp-
tomatology. Therefore, it appears that the presence of
existential purpose and meaning in life may be an
important factor in reducing the negative effects of
attachment issues manifested in important relationships
for individuals with comorbid MDD, dysthymia and
SUDs. However, our results would suggest that purpose
and meaning may not be as important a factor for those
with bipolar disorder.
The differential effects of purpose and meaning on
bipolar and the other two mood disorders could perhaps
be explained by research that has documented bipolar as
being a separate condition from the affective disorders
in that it is 85% heritable (Barnett and Smoller 2009).
The genetic disposition for mania has been described as
independent of the liability for depression (McGuffin
et al. 2003), whereas other subtypes of depressions are
proposed to be based on the internal meanings arising
from feelings of loss (i.e. the attachment system). Thus,
these authors speculate whether the strong neurobio-
logical components associated with bipolar may be more
salient than the influence of existential purpose and
meaning in the life of individuals affected by a dual
diagnosis of bipolar and a substance use disorder.
Clinical implications and conclusions
Our findings have multiple implications that may be
useful in informing clinical interventions pertaining to

individuals with co-occurring substance use and mood
disorders. First, our results suggest that increasing the
existential purpose and meaning dimension of spiritu-
ality may help individuals with adult attachment issues
reduce their levels of depressive symptoms associated
with dysthymia or MDD. Findings also seem to indicate
that increasing individuals’ connectedness to a higher
power may not be as effective. Perhaps future research
will find that the reason that purpose and meaning work
to relieve depressive symptoms in this population stems
from the emotional benefits of having close interpersonal
relationships that provide purpose and meaning in an
individual’s life. It is possible that having someone to
care about and care for may give an individual purpose
and meaning in life that may ultimately buffer the
development and effect of depressive symptoms.
Alternatively, perhaps purpose and meaning acts as a
substitute for close relationships. We speculate whether
an individual can have a satisfying life and positive sense
of self if they have sufficient purpose and meaning
regardless of whether they have meaningful close
relationships. In either case, finding interventions that
help to increase purpose and meaning in life among
dually diagnosed individuals would appear to be of
clinical benefit.
Second, our findings indicated that, although bipolar
disorder is a mood disorder, it is quite different from
MDD and dysthymia. Whereas individuals with MDD
and dysthymia stemming from early attachment issues
may benefit from interventions that increase existential
purpose and meaning, individuals with bipolar may not
respond as well. Perhaps the difference lies in the
genetics of the disorder that drive its manifestation.
Both MDD and dysthymia are disorders of depression

while bipolar may be considered as a disorder of both
depression and mania. It may be that during a manic
episode individuals experience a sense of purpose and
meaning which is not present during a depressive
episode, whereas those with MDD or dysthymia do not
experience those high levels of purpose and meaning
at all.
Limitations and future direction for research
Several limitations need to be considered when inter-
preting the results of this study. First, we used a cross-
sectional design so we can only describe the relationship
among the factors and not make a direct causal
statement; however, path analysis has been used in
other studies to explore relationships among variables to
build statistical models (Shipley 2002; Ye et al. 2014).
This does not allow for an exploration of how attach-
ment style dimensions and spirituality evolve over time
as a result of being in substance use treatment, while
simultaneously exploring changes in depressive symp-
toms. Future studies need to employ a longitudinal
design that could provide evidence related to the extent
to which substance use treatment influence the relation-
ships between these variables. Second, most of the
participant in the study self-identified as Caucasian, and
thus, findings cannot be generalizable to other ethnic/
racial groups. In addition, other sociodemographic
factors including having financial resources (i.e. medical
insurance) and receiving services at a private, for-profit
agency that is based on the 12 steps model whose
population represents clients attending a residential
treatment facility need to be taken into consideration
when interpreting and generalising the results. Other
important information about the participants including
drug of choice, frequency of use, SUDs diagnoses and

severity were not collected in this study. Future studies
should capture this information as these elements may
have a potential effect on the variables under examin-
ation in this investigation. In addition, this study
examined the relationships among attachment style
dimensions and spirituality and three mood disorders.
Future studies may consider exploring the relationships
between these factors and other mental health disorders.
In addition, future research could focus on other possible
aspects of spirituality not examined in this study. For
example, recent research has explored relationships
between purpose and meaning in life and forgiveness
(Lyons et al. 2010, 2011). It would be interesting to
explore possible relationships between attachment
dimensions and these factors.
Another limitation involves the operationalization of
spirituality. Koenig (2008) indicated that instruments
measuring spirituality assess it in terms of religious
practices, positive mental health or both. Many research
studies, in their analyses, do not distinguish between
spirituality and religious well-being. In fact, investiga-
tions exploring the impact of spirituality on different
clinical outcomes measure this construct using tools
design to capture elements related to religious coping
skills and practices (Doolittle and Farrell 2004; Hill et al.
2005; Sorajjakool et al. 2008). Koenig (2008) suggests
that studies using the SWB, such as our study, should
analyse the existential and religious well-being separately
to avoid presenting misleading results. Although analyses
in this study followed Koenig’s (2008) suggestions,

several researchers are questioning whether it is appro-
priate to attribute positive mental health states (i.e.
purpose and meaning in life) as part of spiritual
dimensions (Krause 2008; Tsuang et al. 2007).
In addition, it is important to consider that the
presence of a mood disorder and/or substance use
disorder could influence how clients answered questions
about their attachment style and relationship with other
people. Recent research has identified an association
between depression and romantic relationships that is
more complex than the one tested in this study
(Finkbeiner et al. 2013; Baker and McNulty 2015;
Rehman et al. 2015; Woods et al. 2015). For example,
Finkbeiner et al. (2013) studied a mediation model in
which they found a causal path between relationship
distress (high levels of negative interaction and low levels
of positive interactions) and depression as well as a
reciprocal path between depression (couple interaction
processes) and relationship distress. That is, they found
that relationship distress resulted in depression and that
depression resulted in relationship distress. On the other
hand, Baker and McNulty (2015) found that confronta-
tional behaviours (which tend to be distressing in close
relationships) were actually associated with fewer
relationship problems over time among couples experi-
encing severe relationship problems unless one or both
of the partners was depressed. In these cases, depression
was found to be related to decreased motivation to
resolve their interpersonal problems. Neither of these
studies explored how attachment might be related to
relationship distress. However, longitudinal research by
Rehman et al. (2015) found that higher levels of
depressive symptoms at T1 were related to a larger
decline in relationship satisfaction over time. When

anxiety symptoms were controlled, depressive symptoms
no longer predicted relationship satisfaction. They
suggested that attachment anxiety may be responsible
for producing stress in close relationships that then adds
to depression. It would be interesting in future research
to test a more complex model in which pathways
between attachment dimensions, spirituality dimensions
and depressive symptoms are examined for reciprocity.
It would be useful to understand what kinds of
interventions can be implemented to increase existential
purpose and meaning in life among individuals in
treatment for substance use issues. It would also be
interesting to explore how individuals with early attach-
ment issues and subsequent adult relationship problems
experience existential purpose and meaning in their lives
and how meaningful interpersonal relationships can
provide purpose and meaning or how purpose and
meaning can overcome relationship difficulties. Future
investigations may also consider replicating our study
and expanding it using other mental health disorders
and examining gender and race/ethnicity differences.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the article.
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An empirical study of attachment dimensions and mood
disorders in inpatient substance abuse clients: The mediating
role of
spiritualityIntroductionMethodsResultsDiscussionDeclaration of
interestReferences
Assessing Clients with Addictive Disorders
Levy family – Assessing Clients with Addictive Disorders
In 3-page paper, address the following:
· After watching Episode 1, describe:
· What is Mr. Levy’s perception of the problem?
· What is Mrs. Levy’s perception of the problem?
· What can be some of the implications of the problem on the
family as a whole?
· After watching Episode 2, describe:
· What did you think of Mr. Levy’s social worker’s ideas?
· What were your thoughts of her supervisor’s questions about
her suggested therapies and his advice to Mr. Levy’s
supervisor?
· After watching Episode 3, discuss the following:
· What were your thoughts about the way Mr. Levy’s therapist
responded to what Mr. Levy had to say?
· What were your impressions of how the therapist worked with
Mr. Levy? What did you think about the therapy session as a
whole?

· Informed by your knowledge of pathophysiology, explain the
physiology of deep breathing (a common technique that we use
in helping clients to manage anxiety). Explain how changing
breathing mechanics can alter blood chemistry.
· Describe the therapeutic approach his therapist selected.
Would you use exposure therapy with Mr. Levy? Why or why
not? What evidence exists to support the use of exposure
therapy (or the therapeutic approach you would consider if you
disagree with exposure therapy)?
· In Episode 4, Mr. Levy tells a very difficult story about Kurt,
his platoon officer.
· Discuss how you would have responded to this revelation.
· Describe how this information would inform your therapeutic
approach. What would you say/do next?
· In Episode 5, Mr. Levy’s therapist is having issues with his
story.
· Imagine that you were providing supervision to this therapist,
how would you respond to her concerns?
· Support your approach with evidence-based literature.
RESOURCES
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced
practice psychiatric nurse: A how-to guide for evidence-based
practice (2nd ed.). New York, NY: Springer Publishing
Company.
· Chapter 7, “Motivational Interviewing” (pp. 299–312)
· Chapter 16, “Psychotherapeutic Approaches for Addictions
and Related Disorders” (pp. 565–596)
1. Diagnostic instruments for behavioural addiction: an
overview
Diagnostic instruments for behavioural addiction: an overview.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2736529/
The ethical ABCs of conditional confidentiality.Fisher, Mary

Alice. University of Virginia, Charlottesville, VA, US
https://store.samhsa.gov/system/files/sma13-3992.pdf
Substance Use & Misuse, 50:1786–1794, 2015
Copyright C© 2015 Taylor & Francis Group, LLC
ISSN: 1082-6084 print / 1532-2491 online
DOI: 10.3109/10826084.2015.1050111
ORIGINAL ARTICLE
How Do Females With PTSD and Substance Abuse View 12-
Step
Groups? An Empirical Study of Attitudes and Attendance
Patterns
Lisa M. Najavits1, Hein de Haan2 and Tim Kok2
1Boston University School of Medicine, Boston, Massachusetts,
USA; 2Tactus Addiction Treatment, Deventer,
Netherlands
Background. Self-help groups are beneficial for many
people with addiction, predominantly through 12-
step models. Yet obstacles to attendance also oc-
cur. Objectives. We explored attendance patterns and
attitudes toward self-help groups by 165 outpatient
females with co-occurring posttraumatic stress disor-
der (PTSD) and substance use disorder (SUD), the
first study of its kind. Methods. Cross-sectional self-

report data compared adults versus adolescents, and
those currently attending self-help versus not attend-
ing. We also explored attendance in relation to per-
ceptions of the PTSD/SUD relationship and symptom
severity. Results. Adults reported higher attendance at
self-help than adolescents, both lifetime and currently.
Among current attendees, adults also attended more
weekly groups than adolescents. Yet only a minority
of both age cohorts attended any self-help in the past
week. Adults perceived a stronger relationship between
PTSD and SUD than adolescents, but both age groups
gave low ratings to the fact that self-help groups do not
address PTSD. That item also had low ratings by both
those currently attending and not attending self-help.
Analysis of those not currently attending identified ad-
ditional negative attitudes toward self-help (spiritual-
ity, addiction as a life-long illness, sayings, and the fel-
lowship). Symptom severity was not associated with
attendance, but may reflect a floor effect. Finally, a
surprising finding was that all-female groups were not
preferred by any subsample. Conclusions/Importance.
Creative solutions are needed to address obstacles to
self-help among this population. Addressing trauma
and PTSD, not just SUD, was valued by females we
surveyed, and may be more helpful than all-female
groups per se.
Keywords PTSD, substance abuse, 12-step groups, self-help,
attitudes, females
Address correspondence to Lisa M. Najavits, VA Boston
Healthcare System, 150 S. Huntington Ave., Boston, MA 02130,
USA; E-mail:
[email protected]
Twelve-step self-help groups are one of the most com-
mon resources for recovery from substance use disorder.

Alcoholics Anonymous (AA) is the most well-known 12-
step group and, from its start in 1935, has grown to over
two million members world-wide across 170 countries
(Alcoholics Anonymous, 2013). Indeed, membership has
increased steadily over the past 40 years (Donovan, In-
galsbe, Benbow, & Daley, 2013). There are also numerous
12-step groups for addictions of all kinds, such as Gam-
blers Anonymous, Overeaters Anonymous, and Sex Ad-
dicts Anonymous. The range of spin-off groups has be-
come remarkably broad, with groups such as Clutterers
Anonymous and Underearners Anonymous (Wikipedia,
2014).
Twelve-step groups have been studied primarily in
relation to substances, with consistent positive findings
(Donovan et al., 2013; Pagano, White, Kelly, Stout, &
Tonigan, 2013; Tonigan, Toscova, & Miller, 1996). Yet
repeated concerns have been raised about obstacles to 12-
step attendance. Most people with addiction do not attend
12-step groups, despite the fact that they are free and exist
in many geographic areas. Perceived difficulties include
issues such as their spiritual focus; the assumption that
addiction is a life-long disease; the emphasis on groups,
which can be challenging for people with social phobia;
and the predominance of men at meetings (Donovan et al.,
2013; Najavits, 2002).
Aside from these general obstacles, there have been
questions about whether some populations may have par-
ticular difficulty with 12-step groups—such as women,
minorities, youth, and people with comorbid mental ill-
ness. Such subgroups may feel outnumbered at meet-
ings or may feel marginalized due to their life experi-
ences. Thus, specialized meetings have arisen for women,
young people, some ethnic and racial minorities, les-
bian/gay/bisexual/transgendered (LGBT), and the men-

tally ill (the latter with groups such as “Double Trou-
ble” and “Dual Disorders Anonymous” groups). There
1786
HOW DO FEMALES WITH PTSD AND SUBSTANCE ABUSE
VIEW 12-STEP GROUPS 1787
have also been reworking of the 12-steps, such as steps
for women (Kasl, 1992) and Native Americans (Travers,
2009).
One important population that has received little atten-
tion in relation to 12-step groups, despite its importance,
is people with co-occurring posttraumatic stress disor-
der (PTSD). PTSD co-occurs frequently with substance
use disorder (SUD), gambling disorder, and other addic-
tive behavior (Najavits, Meyer, Johnson, & Korn, 2011;
Ouimette and Read, 2014). The two disorders also im-
pact each other over time, with each typically making the
other worse, in a downward spiral (Najavits, Weiss, &
Shaw, 1997; Najavits, 2014). Various treatment options
have been developed for the comorbidity over the past two
decades (Najavits and Hien, 2013), including, recently,
the first pilot study of a peer-led option (Najavits et al.,
2014).
Twelve-step models, which are the most widely acces-
sible and free option for addiction, do not directly address
trauma or PTSD. This is likely due to the historical de-
velopment of AA, which arose in an era with little focus
on trauma. The 12 steps do not focus on harm done to
the addict, such as trauma, but rather just on harm the ad-
dict has done toward self and others. Thus, it has been un-

clear whether people with comorbid PTSD and addiction
would find 12-step groups appealing. Some of the 12 steps
could be perceived negatively by trauma survivors. For ex-
ample, Step 1, “We admitted we were powerless over our
addiction. . .” may be at odds with the empowerment that
is emphasized as helpful for trauma survivors (Najavits,
2002). Steps 4–9 focus on the addict’s shortcomings and
do not address harm done to the addict: “Admitted. . .the
exact nature of our wrongs”, “Were. . .ready to have God
remove these defects of character,” “Made a list of all per-
sons we had harmed”. Also, many trauma survivors are
women and the predominance of males at 12-step meet-
ings may be intimidating to them, especially if they suf-
fered interpersonal violence by males. Trauma survivors
may avoid social interactions (especially large groups),
may have difficulty trusting others and talking about their
past, and may have lost faith in a higher power, thus fur-
ther making self-help group attendance potentially prob-
lematic. The 12-step emphasis on the role of substance use
as the primary cause of an individual’s current difficulties
may differ from a trauma survivor who views her PTSD
symptoms as primary.
However, there are also compelling reasons to believe
that 12-step groups can be healing for people with PTSD.
Such groups can provide a welcoming community to
help counter the isolation and stigma that are common in
trauma. The openness and acceptance of 12-step groups
can mitigate secrecy and shame. The groups’ spirituality
and sense of purpose can counteract hopelessness. Thus,
various writers have stated that self-help group attendance
may be a helpful component of aftercare for people with
PTSD and SUD (Brown, 1994; Evans & Sullivan, 1995;
Satel, Becker, & Dan, 1993), although even early on it
was suggested that adaptations might be needed (Brown,
1994).

We know of no studies that have directly addressed
12-step attitudes and attendance among females with
PTSD/SUD. There have been studies of male veterans
with PTSD/SUD such as the research of Ouimette and
colleagues (Ouimette, Moos, & Finney, 2000). However,
male veterans’ response to 12-step groups may be very
different than community-based females. Thus, we sought
to explore several key topics in relation to females with
PTSD/SUD and self-help groups: (1) attendance patterns;
(2) attitudes toward such groups; and (3) beliefs about
the linkages between PTSD and SUD. In addition, we
compared adults versus adolescents and those currently
attending self-help groups versus not attending, as these
subsamples may differ in their results. We also evalu-
ated whether addiction and mental health symptom sever-
ity might help explain attendance versus nonattendance at
self-help groups. We did not have a priori hypotheses on
the direction of expected results as this is the first study
we know of to explore this set of topics in this population.
METHODS
Participants
We used data from four datasets, all of which were origi-
nally collected with IRB approval from McLean Hospital,
and on which the first author was either the principal in-
vestigator (studies #1–3 below) or co-investigator (study
# 4 below). For the current paper, IRB approval for sec-
ondary data analysis was obtained in April, 2014 from
Partners Healthcare System which is the current IRB of
record for McLean Hospital. All four studies had rigor-
ously diagnosed samples with current PTSD and current
SUD, using DSM-IV criteria. The four studies were: (1)
a pilot study of 32 adult women funded by the National
Institute on Drug Abuse (NIDA; #DA-09400; Najavits,

Weiss, Shaw, & Muenz, 1998); (2) a study of 34 adoles-
cent girls funded by the National Institute on Alcohol and
Alcoholism (#R21 AA-12181; Najavits, Gallop, & Weiss,
2006); (3) a study of 97 women funded by NIDA (#DA-
086321; Najavits, Sonn, Walsh, & Weiss, 2004); and (4)
a study of 62 women, comparing those with PTSD/SUD
to those with PTSD alone funded by the Falk Founda-
tion (Najavits, Weiss, & Shaw, 1999), from which we used
only the co-morbid portion of the sample. For all studies
that had data at multiple timepoints, we used only base-
line data, thus using a cross-sectional design for this pa-
per. All samples were community-based outpatients. In
all three adults studies, all of the women met current cri-
teria for substance dependence, the most severe form of
SUD; and in the adolescent study, 94% had current sub-
stance dependence. All studies included both alcohol and
drug use diagnoses. The average age for the adult samples
ranged from 35.9 (SD = 8.53) to 38.17 (SD = 8.56); and
for adolescents was 16.06 (SD = 1.22). The final sample
size for this paper, n = 165, reflects those for whom data
was available on either one or both of the two key mea-
sures in this paper: the self-help measure (n = 126) and/or
the attitudes toward PTSD/SUD measure (n = 165), each
described below. The measures were missing on some
1788 L. M. NAJAVITS ET AL.
participants due to lack of completion or, in some cases,
entering the study prior to a measure being added to the
assessment battery.
Measures
Diagnoses of current PTSD and SUD were obtained from
the Structured Clinical Interview for DSM-IV (SCID;

First, Spitzer, Gibbon, & Williams, 1996). The SCID
was administered by assessors who had a degree in men-
tal health (social work or psychology) and were trained
on the measure using methods per the NIDA Collabo-
rative Cocaine Study (Crits-Christoph et al., 1997). For
self-help attitudes and attendance, the Modified Weekly
Self-Help Questionnaire was used (MWSHQ; Weiss and
Najavits, 1994). That measure was modified from the orig-
inal Weekly Self-Help Questionnaire (WSHQ) to include
questions related to PTSD. The original WSHQ had al-
ready shown strong internal consistency and has been used
in other studies (Weiss et al., 1996; Weiss et al., 2005).
All items from the MWSHQ that were used in this pa-
per are listed in Tables 1 and 2. The MWSHQ items in
this study had several formats: yes/no (e.g., have you at-
tended a self-help group in the past week?); numeric (e.g.,
how many self-help groups have you attended in the past
week); and Likert (e.g., rate how much you agree with
the following statement. . .). “Self-help” in the measure
refers to 12-step groups and non-12-step groups with the
latter including Rational Recovery, for example. Non-12-
step groups are referred to as “non-spiritual” per Tables
1 and 2. We also analyzed the Questionnaire on Attitudes
toward PTSD-SUD (Najavits, 1997), for both adults and
adolescents, with all items listed in Table 3. Finally, for
the three adult studies, we also had the Addiction Sever-
ity Index (McLellan et al., 1992) and the Brief Symptom
Inventory (Derogatis, 1983), and we used data from these
in relation to our self-help questions.
Data Analysis
Data were converted to z-scores as needed when scaling
was not consistent across measures. We used descriptive
statistics and independent-samples t-tests or chi squares to
compare subsamples (e.g., adult versus adolescents; those
currently attending self-help groups versus those not at-

tending). T-tests were used for continuous data and chi
squares for categorical data. We did not adjust for multiple
comparisons, such as Bonferroni correction, due to known
problems of low statistical power and other concerns as-
sociated with such correction, particularly for exploratory
studies such as this one (Nakagawa, 2004).
RESULTS
Use of Self-Help Groups
As shown in Table 1, most of the adult sample (84%) re-
ported having attended a substance abuse self-help group
at some point in their life, but only about one-third had at-
tended a group in the past week and relatively few had
a sponsor (22%). Adolescents reported generally lower
self-help attendance than adults, both lifetime and in their
average number of groups in the past week. Even when
looking only at those currently attending self-help groups,
adolescents attended fewer groups in the past week than
their adult counterparts. It is also notable in Table 1 that
the adult women currently attending had attended an av-
erage of over four groups per week—a large number, es-
pecially for an outpatient sample.
Attitudes Toward Self-Help Groups
To study attitudes toward self-help groups, we first com-
pared adults and adolescents on each of the statements
listed in Table 2 (except for the few that were not asked of
the adolescent sample, as indicated there). T-tests revealed
no significant differences between them on any attitudes
toward self-help groups and thus the adult and adolescent
data were combined in Table 2. We next compared those
currently attending self-help groups versus those not cur-
rently attending, as our goal was to understand whether
any particular beliefs about self-help groups might help

explain attendance.
Several main results are evident in Table 2. First, the
two groups (currently attending and not currently attend-
ing) differed on many attitudes. Of the 14 attitudes on
which we compared the two groups, seven were signifi-
cant, and in all cases those currently attending were more
positive in their attitudes toward self-help groups. Sec-
ond, one of the lowest-rated items for both groups re-
lated to PTSD (item 11), indicating that participants would
have wanted self-help groups to address PTSD. Third, we
found that there was not a strong preference for having all
female self-help groups (item 13).
Beliefs About the Relationship Between PTSD and SUD
In Table 3, we explored how participants viewed the link-
ages between PTSD and SUD. Adults and adolescents
differed significantly on all ten comparisons, and always
in the same direction, with adults reporting stronger en-
dorsement on all items. This indicated that adults viewed
their PTSD and SUD as being related far more than did
adolescents. In looking at the items endorsed by adults,
it also appears that they viewed both disorders as impor-
tant to address (e.g., items 3 and 4). There did not ap-
pear to be a pattern of them believing that one disorder
was consistently more important or central than the other.
We also conducted a comparison of adults who had at-
tended a self-help group in the past week versus those who
had not, and found no significant differences on any item.
We were unable to examine this issue among adolescents,
given the small sample size for those data. We also could
not combine the adults and adolescents as they differed on
this questionnaire (as detailed above), and this would have
confounded age group versus attendance patterns.
Relationship Between Self-Help Use and Symptom

Severity
The final question we explored was whether women cur-
rently attending versus not attending self-help groups dif-
fered in their severity of symptoms. We compared them
on the Addiction Severity Index (ASI; all seven compos-
ite scores), which addresses SUD-related symptoms, and
on the Brief Symptom Inventory (BSI; global severity
TABLE 1 . Adult versus adolescent attendance at self-help
groups
Adults Adolescents Comparison
Ever attended a substance
abuse self-help group
Total sample 84% (n = 75) 57% (n = 21) X2(1) = 6.93∗ ∗
Attended at least one
substance abuse self-help
group in past week
Total sample 32% (n = 103) 44% (n = 23) X2(1) = 1.09
Mean number of substance Total sample 1.32 (SD = 2.31) (n =
103) .70 (SD = .98) (n = 23) t(82.63) = −2.02∗
abuse self-help groups
attended in past week
Those currently attending 4.12 (SD = 2.27) (n = 33) 1.61 (SD =
.86) (n = 10) t(38.72) = −5.23∗ ∗

Currently has a sponsor Total sample 22% (n = 97) – –
Those currently attending 48% (n = 31) – –
∗ p < .05
∗ ∗ p < .01
index), which addresses general psychiatric symptoms.
The two subsamples did not differ on any variable on
either measure. This indicates that attendance at self-
help groups cannot be explained by severity of addic-
tion or psychiatric symptoms. Similarly, there were also
no significant differences in ASI and BSI scores between
women with sponsors and women without sponsors. We
did not include adolescents in the analysis of the ASI or
BSI as they had not completed these measures, which
were designed for adults.
Qualitative Comments
Participants who did not attend self-help groups were
asked why they did not. Several comments related directly
to trauma: “The religious undertones trigger memories of
past ritual abuse”; “I do not believe that substance abuse
or PTSD are lifelong problems”; “I get very anxious”; “I
get hit on by older men”; “I hate AA– people just abuse
you there”; “I’ve never found an all-women AA group
and I can’t say no to sex”; and “I grew up with an alco-
holic/abusive father.”
Others who did not attend self-help groups focused
on addiction-related points, such as: “They trigger me to
drink; I am sober in a different way than AA thinks about”;
“I don’t go when I’m actively using”; “AA doesn’t make
sense—’Only God can keep me away from a drink’?”; “I
don’t want to eliminate alcohol”; and “I hate drunkalogs
from AA members.”

Some comments were highly positive about meetings:
“It’s a great way to slow myself down”; “I like the educa-
tional aspects which can redirect my thinking”; “It helps
to know that you’re not the only one!” and “They give me
hope, it’s good to know there are so many meetings; I can
go to one anytime.”
DISCUSSION
Self-help groups such as Alcoholics Anonymous have
long been a prominent resource for SUD recovery. How-
ever, it is unclear how such groups are perceived by fe-
males with co-occurring PTSD and SUD. In this arti-
cle, we explored women and adolescent girls’ views of
such groups (which are predominantly 12-step), their at-
tendance, how severity of substance problems and mental
illness relate to attendance, and beliefs about the relation-
ship between PTSD and SUD. This is the first article we
know of to empirically address these topics in this pop-
ulation. Other strengths of this study include participants
who were rigorously diagnosed with current PTSD and
SUD, and a good sample size for a descriptive study such
as this.
Our first main finding was that the adult women in our
sample reported significantly higher attendance at self-
help groups than did adolescent girls. This result is con-
sistent with prior research, which indicates that although
adolescents are often referred to self-help groups for sub-
stance problems, their attendance is low (Kelly, Myers,
& Rodolico, 2008). New developmentally appropriate in-
terventions may be needed for adolescents who may not
be mature enough to benefit from adult models such as
12-step groups. The 12-step emphasis on “hitting bot-

tom,” for example, may be more relevant to adults who
have had more time and experience to observe the conse-
quences of their addiction. In general, research finds that
adolescents have better attendance at 12-step groups the
more they have age similarity with attendees (Kelly, My-
ers, & Brown, 2005). Also, when they do attend 12-step
groups, adolescents are found to show improvement on
SUD, although the literature is early and methodologi-
cally limited (Bekkering, Marien, Parylo, & Hannes, in
press). We know of no adolescent-specific 12-step move-
ment that is formally part of the central service orga-
nization. Thus adolescents, when they do attend, go to
groups designed for adults. We were able to identify a
privately created school-based adolescent 12-step model
that strives to enhance adolescent engagement through
features such as an adolescent version of the 12 steps
(www.teenaddictionanonymous.com, 2014). Such efforts
hold promise and warrant research attention. Also, non-
12-step models may also be relevant for adolescents,
such as SMART Recovery. Adolescents surveyed about
their attitudes towards AA, the most common 12-step
TABLE 2 . Attitudes towards self-help groups1
Currently Attending
Self-Help Groups
Not Currently Attending
Self-Help Groups
Mean (SD) n Mean (SD) n t df

1. Self-help groups have
helped with my substance
abuse+
.63 (1.08) 7 −.43 (.76) 8 −2.23∗ 13
2. I like the spirituality in
self-help meetings
.59 (.92) 39 −.24 (.92) 68 −4.52∗ ∗ 105
3. I like the 12 steps .57 (.87) 30 −.26 (.95) 59 −4.03∗ ∗ 87
4. I like substance abuse
self-help groups
.50 (.81) 30 −.25 (1.00) 53 −3.70∗ ∗ 71.26
5. I like the sayings in
self-help groups (e.g., “One
day at a time”)+
.48 (.84) 22 −.20 (1.00) 53 −2.82∗ ∗ 73
6. I like the community
(“fellowship”) at meetings
.47 (.75) 35 −.22 (1.02) 66 −3.89∗ ∗ 88.71
7. I like the people I meet in
spiritually-based 12-step
meetings+
.42 (1.19) 9 .13 (.79) 10 −.63 17
8. I agree that addiction is a
lifelong illness

.39 (.95) 39 −.15 (1.01) 70 −2.76∗ ∗ 107
9. I like the idea that self-help
groups call
alcoholism/addiction a
disease+
.36 (1.25) 9 −.23 (.84) 10 −1.22 17
10. I like the people I meet in
non-spiritual self-help
meetings+
.18 (1.33) 9 −.26 (.49) 10 −.94 9.94
11. I like it that trauma/PTSD
is not talked about at substance
abuse self-help groups
.02 (1.06) 28 −.001 (.98) 59 −.11 85
12. I like non-spiritual
self-help groups (e.g., Rational
Recovery)+
−.03 (1.28) 30 −.02 (.88) 62 .06 42.74
13. I like groups that are
all-female
−.04 (.85) 38 .07 (1.06) 71 .57 107
14. Self-help groups have
made my substance abuse
worse+

−.25 (.61) 9 .30 (1.46) 6 1.03 13
p < .05
∗ ∗ p < .01
+Refers to a question not asked across all datasets (thus a lower
n).
1For this analysis, adults and adolescents were combined. This
table is arranged from highest to lowest endorsement of beliefs
of those
currently attending self-help groups.
group, express positive views of support groups per se, but
less positive views of the 12-step content, with the most
common concerns related to boredom and lack of fit
(Kelly, Myers, & Rodolico, 2008).
With regard to PTSD, a notable finding in our study was
that respondents gave low ratings to the fact that PTSD
is not addressed in self-help groups. Twelve-step groups,
by far the most common self-help type, was designed to
address addiction only, not trauma, PTSD, or other men-
tal health issues. Our finding suggests that more options
are needed for PTSD recovery. There are currently no
widely available self-help groups for PTSD or trauma.
Over the years, some groups have arisen, such as Sur-
vivors of Incest Anonymous, but they have never become
widespread, perhaps because the dynamics of a trauma
group are different than a SUD group and because of
challenges when people “spill” their trauma story, which
can be destabilizing. The only PTSD/SUD model that has
as yet been tested in peer-led format is Seeking Safety,
with positive findings (Najavits et al., 2014). That model
takes a present-focused approach that reduces the inten-
sity of sharing trauma stories and also addresses PTSD

and SUD at the same time in integrated fashion, explor-
ing their interrelationship.
We found that the study subsamples who were not
currently attending self-help—which was the majority of
both adult and adolescents—had more negative views of
self-help groups. They were less positive about the spiri-
TABLE 3 . Beliefs about the relationship between PTSD and
substance abuse
Adults Adolescents
Mean (SD) n Mean (SD) n t df
1. My substance abuse and my
PTSD are strongly related
.25 (.75) 130 −1.37 (1.09) 24 −6.99∗ ∗ 27.14
2. My substance abuse is a
symptom of my PTSD
.22 (.87) 138 −1.24 (.80) 24 −7.71∗ ∗ 160
3. My substance abuse will
never get better until I deal
with my PTSD
.19 (.89) 137 −1.17 (.87) 22 −6.66∗ ∗ 157

4. My PTSD will never get
better until I stop substance
abuse
.18 (.89) 137 −1.13 (.94) 22 .−6.39∗ ∗ 157
5. If I stopped my substance
abuse, my PTSD would get
better
.18 (.93) 136 −1.56 (.63) 21 −8.36∗ ∗ 34.78
6. My substance abuse
problem is worse than my
PTSD
.14 (.98) 139 −.83 (.72) 23 −5.61∗ ∗ 36.84
7. I would be happy if my
PTSD got better, even if my
substance abuse didn’t
.14 (1.01) 135 −.73 (.55) 26 −6.31∗ ∗ 62.42
8. If I stopped my substance
abuse, my PTSD would get
worse
.13 (.98) 135 −.85 (.69) 21 −5.72∗ ∗ 34.13
9. My PTSD is worse than my
substance abuse
.12 (.96) 138 −.72 (.98) 22 −3.80∗ ∗ 158
10. I would be happy if my

substance abuse got better,
even if my PTSD didn’t
.10 (1.02) 136 −.55 (.68) 25 −4.02∗ ∗ 46.33
∗ p < .05
∗ ∗ p < .01
tuality of the groups, the focus on addiction as a life-long
illness, the sayings, the fellowship, etc. Although this is a
fairly obvious finding—those who attend the groups like
them more—on another level, it underscores that many
females with PTSD/SUD may have real obstacles to self-
help attendance. Such obstacles may be rooted in these
types of beliefs, and also in other obstacles that were
not part of the study measure. Some participants’ open-
response comments highlight trauma-related issues such
as fear of men at meetings and feeling triggered, for ex-
ample. Whatever the mix of issues that limit self-help at-
tendance by females with PTSD/SUD, it is notable that
symptom severity does not explain it, at least based on
our sample in which neither SUD nor mental health sever-
ity were associated with attendance. However, these null
findings likely reflect a floor effect. We used only baseline
data and participants were included only if their symptom
severity was sufficient to meet our entry criteria of cur-
rent PTSD, which focused on past-month symptoms; and
current SUD, which was substance dependence, the most
severe form. Other research that explores attendance lon-
gitudinally has found, in contrast, that more severe sub-
stance use is associated with greater self-help attendance
in both adults (Kelly, Stout, Zywiak, & Schneider, 2006)
(Weiss et al., 2000) and adolescents (Kelly, Myers, &
Brown, 2002).
It also must be emphasized that, in keeping with prior

studies, some females with PTSD clearly do find self-
help groups helpful. In our study, those who were attend-
ing attended a large number of week meetings (an aver-
age of four among the adults in our sample). Some par-
ticipants also commented on how helpful they found the
meetings.
Finally, and somewhat surprising, our sample, both
adults and adolescents, did not endorse a strong pref-
erence for all-female self-help groups. This suggests
that gender per se may not be the key consideration
in their attitudes toward self-help groups. The sample
appeared stronger in their desire for PTSD to be ad-
dressed (item 11 in Table 2). However, future research
would be needed to disaggregate gender and diagnoses as
our sample all shared the same gender and PTSD/SUD
diagnoses.
There are many directions for future research. Our
study was limited to secondary analysis and a combi-
nation of several datasets. Due to the exploratory na-
ture of the study, there was also no control for the
number of statistical comparisons. A prospective, larger
study would be useful, especially if it could address how
symptoms of PTSD and SUD change in relation to self-
help group attendance. It may also be helpful to de-
velop a guide to encourage self-help attendance among fe-
males with PTSD/SUD, such as the evidence-based meth-
ods of 12-Step Facilitation (Project MATCH Research
Group, 1997) and Making Alcoholics Anonymous Easier
(Kaskutas, Subbaraman, Witbrodt, & Zemore, 2009).

Even people with SUD but no PTSD have obstacles
to self-help groups (Donovan et al., 2013), which led
to the development of these facilitative interventions.
Adapting them for PTSD explicitly could be useful. Fi-
nally, it is worth considering new self-help models be-
yond traditional 12-step groups. In recent years there
is greater focus on peer-led help for all sorts of men-
tal health and medical problems (Substance Abuse and
Mental Health Services Administration, 2009). Peer-
led Seeking Safety (Najavits et al., 2014) can be po-
tentially expanded and other PTSD/SUD models could
also be tested in self-help format (Najavits & Hien,
2013). Prior studies have shown that patients with
PTSD and SUD prefer to focus on both disorders or
on their PTSD; they are least positive about focusing
just on SUD (Brown, Stout, & Gannon-Rowley, 1998;
Najavits, Sullivan, Schmitz, Weiss, & Lee, 2004). We
must remember that recovery from SUD is more compli-
cated in the context of PTSD. Numerous studies show that
relative to individuals with SUD only, those with PTSD
and SUD have greater impairment and worse outcomes
(Najavits et al., 2007; Ouimette and Read, 2014). Thus,
it will be important to keep refining our understanding of
what makes it difficult for females with PTSD to engage
in some SUD treatments, and of finding treatment options
that appeal to them.
DECLARATION OF INTEREST
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the
article.
FUNDING
This work was supported by the U.S. Department of De-

fense [grant number W81XWH-10-2-0173].
GLOSSARY
Posttraumatic stress disorder: (PTSD) may develop after
a traumatic event, which is a terrifying physical or sex-
ually violent event that may be experienced, witnessed,
or threatened, for example. Such events include combat
exposure, terrorist attack, sexual or physical assault, se-
rious accidents, and natural disasters. In DSM-5 PTSD
symptom clusters are intrusion, avoidance, negative al-
terations in cognitions and mood, and alterations in
arousal and reactivity.
Substance use disorder (SUD): is a condition in which the
use of a substance, such as alcohol, cocaine, heroin, or
others, leads to clinically significant impairment or dis-
tress. In DSM-5 it is termed “Substance-Related and
Addictive Disorders” and can be classified as mild,
moderate or severe depending on the number of symp-
toms met.
Self-help groups: Also known as support groups, and mu-
tual aid groups, these are comprised of people who
work on a volunteer basis in regular meetings to help
each other with a common problem. They are widely
used in the SUD field, with diverse methods, ranging
from more secular to predominantly spiritual.
12-step groups: These groups are a specific type of self-
help group that relies on the 12 steps, which are a set of
guiding principles with a spiritual focus to help people
with addiction engage in recovery. Alcoholics Anony-
mous is the largest and earliest of all 12-step programs,
but the model is also used by Narcotics Anonymous,

Cocaine Anonymous and many others.
THE AUTHORS
Lisa M. Najavits,
PhD, is professor of
psychiatry, Boston
University School of
Medicine; and lecturer,
Harvard Medical
School. She is a
research psychologist
at Veterans Affairs
(VA) Boston
Healthcare System
and the Bedford VA;
clinical associate,
McLean Hospital; and
director of Treatment
Innovations. Her
major interests are
substance abuse, trauma, co-morbidity, behavioral addictions,
veterans’ mental health, community-based care, development
of new psychotherapies, and outcome research. She is author of
over 180 professional publications, as well as the books Seeking
Safety: A Treatment Manual for PTSD and Substance Abuse;
and
A Woman’s Addiction Workbook. She also serves on numerous
advisory boards.
Hein de Haan,
MD/PhD, is a
psychiatrist and
medical director of
Tactus Addiction
Treatment Program

in the Netherlands.
He also participates
as a researcher at
Nijmegen Institute for
Scientist-Practitioners
in Addiction. His
research topics include
trauma, PTSD and
addiction, alexithymia,
online therapies for
addictive disorders,
and forensic addiction
treatment.
Tim Kok, MSc, is
a psychologist at
Tactus Addiction
Treatment Program
in the Netherlands
and is in training for
a doctoral degree in
clinical psychology.
He participates as a
researcher at Nijmegen
Institute for Scientist-
Practitioners in
Addiction. His dissertation is on trauma and addiction, and
some
of his recent work includes the development and validation of
existing screening instruments for PTSD and studying ways of

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