Understanding addiction through the lens of Attachment

by Aoife Ward

Addiction is a branch of psychotherapy sometimes avoided by general clinicians due to a fear of the complex ways in which it presents in clients. As a training psychotherapist with a strong interest in working with those experiencing addiction, I am intrigued by the segregation between general psychotherapists and addiction therapists. Through researching myriad approaches to working with people with addictive behaviours, I hope to deepen my understanding of the roots of addiction, the ways in which it manifests in individuals, and how to address it in the therapeutic context.

This article advocates a multi-faceted approach to addiction treatment and recovery, and offers attachment theory as a framework for psychotherapists to apply in the clinical setting. It moves away from the religious theories of anonymous addiction groups, and pulls together research on the correlation between childhood trauma and adult addiction, as well as the healing power of the therapeutic relationship as secure base. It looks at Motivational Interviewing as a useful tool for initial assessment, at the individual therapeutic relationship as a corrective parental substitute that the individual can attach to instead of remaining attached to addictive behaviours, and at the efficacy of group therapy in addiction, positing group as a further transitional object for the individual to attach to before reaching out to form healthy boundaried relationships in their life, and avoid relapse.

The nature of addiction

Addiction is a self-defeating energy that abuses our freedom and enslaves desire. Its psychological, neurological and spiritual dynamics are actively at work within all of us
                                                                                            (May, 1988: 3).

Gerald May’s 1988 Christian text Addiction and Grace proposes the above quote as a definition of addiction. While it is true that addiction is a “prevalent, multi-dimensional disorder, affecting the mind, body and spirit” (Powers, 2017: 60), the overall sentiment may be problematic when removed from its religious context. Describing addiction as a self- defeating energy ignores the meaning behind its development in the life of an individual. As outlined by Vincent Felitti, “dismissing addictions as ‘bad habits’ or ‘self-destructive behaviour’ comfortably hides their functionality in the life of the addict” (Maté, 2008: 33). If we are to work with those who experience addiction in a psychotherapeutic model, it is imperative to discover the meaning behind the development of their damaging behaviour, rather than viewing it as an entity that is to be distrusted and eradicated at all costs.

Addiction is often misconstrued as a gluttonous hunger for a high, much like the preliminary “chronic pleasure” alluded to by Thomas de Quincy in Confessions of an English Opium Eater. De Quincy spoke of his experience with opiates as a wondrous escape from reality:

a healthy restoration to that state which the mind would naturally recover upon the removal of any deep-seated irritation of pain that had disturbed and quarreled with the impulses of a heart originally just and good
                                                                  (De Quincy, 1821/1995: 41-42).

In effect, he describes a feeling of wholeness and balance synonymous with healthy emotional regulation. This is consistent with psychoanalyst Heinz Kohut’s assumption that all addictions are “misguided attempts at affect-regulation and self-repair” (Flores, 2001: 67).

Features of addiction
Since clients with addiction may be apprehensive about admitting to its prevalence in their lives, it is the role of the therapist to be aware of the common behavioural and relational features the client may display, and to gently draw the client’s attention to them in order to question their function. The characteristics of an active addict will include some of the following:

i)  Chronic abuse of a substance or behaviour
ii)  Impulsivity and recklessness (Cea et al., 2016)
iii)  Difficulty with delayed gratification (Van Horn & Frank, 1998), and therefore with treatment retention
iv)  Repetition enactment and ritual, in order to gain control over current events where they were powerless in the past (Miller, 2002)
v)  Counterdependence in relationships, ‘autonomy is purchased at the price of alienation and the absence of mutuality in their relationships’ (Flores, 2001)
vi)  Sadomasochistic, maladaptive, or exploitative relational patterns (Flores, 2001)
vii)  Denial of addiction, ambivalence (Holleran Steiker, 2009)
viii)  Relapse

For therapists the final point can be the most difficult to accept, but addiction truly is characterised by relapses (Maté, 2008), with worldwide relapse rates estimated at 70% (United Nations Office on Drugs and Crime, 2003). Therapists who work with addicted persons must be patient, and hold the hope for a client who faces repeated relapses.

The path to addiction
Initial experimentation with illegal substances is common in adolescence, yet those who really struggle during this crucial period of expansion are likely to develop ongoing addiction to substances and behaviours which are damaging to their overall wellbeing (Karavalaki & Shumaker, 2016). The reasons for this may be multi-faceted, but according to Hofler et al., addiction can be understood as a deeply rooted “fear of intimacy” (Hofler & Kooyman, 1996: 517). Karavalaki suggests that drug abuse in adolescents may be a way of coping with the inherent loneliness of being separate from mother. In order to understand this fear, we must look at the client’s past, often going back to their earliest childhood experiences. There is a rising body of research confirming that “traumatic early childhood experiences and insecure attachments are both independent and interrelated risk factors for developing substance abuse disorders” (Fletcher et al., 2015: 109). Indeed, the correlation between poor attachment styles and later development of addiction is strong; “the more trauma and neglect to which a child is exposed at an early age, the more likely it is he/she will develop a substance abuse problem” (Fletcher et al., 2015: 114). A 2003 study of the impact of adverse childhood experiences (ACEs) on the likelihood that an individual would later abuse substances showed that “the effects of adverse childhood experiences transcend secular changes such as increased availability of drugs, social attitudes toward drugs, and recent massive expenditures and public information campaigns to prevent drug use” (Dube et al., 2003: 564), and instead demonstrate a strong link between a high number of ACEs and chronic drug abuse.

Working with addiction
Since active addiction and recovery are complex and many layered processes, a multifactorial approach is needed to address them. Unlike some forms of generic psychotherapy, the clinician must be versed in working with a range of other professionals in order to assist a client. A holistic method of treating addiction may include “medically assisted detoxification, behavioural interventions, medication management, treatment for co-occurring disorders, trauma-informed services, individual psychotherapy, group therapy” and family support services (Tronnier, 2015: 234-235).

In Drugnet Ireland’s 2018 report on opiate dependence,

the most positive outcomes for remaining in treatment and for benefits from treatment (e.g. reduced drug use) were seen when a person-centred, holistic approach, including psychosocial interventions, was delivered in conjunction with medication assisted treatment.
                                                                                           (Millar, 2018: 3).

The models used by those in the field of psychotherapy vary from a classical Rogerian approach to the more directive process of Motivational Interviewing. Increasingly, attachment theory is being recognised as a potential framework for psychotherapists to use when helping those suffering with addiction to substances and behaviours (Darke, 2012; Fletcher et al., 2015; Flores, 2001; Hofler et al., 1996; Tronnier, 2015).

Motivational Interviewing
Motivational Interviewing is a person-centred approach that is also directive in nature. When William Miller and Stephen Rollnick formed the methodology in the 1980s, it was a softer alternative to the unsympathetic therapies built on shaming clients that were previously used. Its goal is to elicit ‘change talk’ in the client by allowing them to explore their ambivalence around their addictive behaviour (Holleran Steiker, 2009). Motivational Interviewing has been championed as an effective mode of working with addiction, specifically in the assessment stages. It seems to be a useful tool in helping clients to move through the denial associated with their defence mechanisms around addiction towards understanding of its positive and many negative effects on their lives. Although “Motivational Interviewing [is one] of the most evidence-based treatment methods used in outpatient and inpatient addiction treatment centers” (Fletcher et al., 2015: 110) and it has been used widely for 40 years, substance abuse rates continue to rise (Weegmann, 2002). A long-term treatment to follow Motivational Interviewing would be constructive in order to support the client through recovery and towards a life full of relationships more rewarding than their years spent addicted (Flores, 2001).

Understanding addiction through the lens of attachment
The parallel between unhealthy attachment bonds and adult development of addiction has been well documented and examined in the last 20 years (Darke, 2012; Fletcher et al., 2015; Flores, 2001; Hofler et al., 1996; Maté, 2008). Therefore, Bowlby’s theory of attachment has significance as a model with which to explore addiction and its meaning within psychotherapeutic practice. The attachment bond represents how infants survive by depending on their parent figures physically, neurologically, emotionally and spiritually.

The following quote highlights the importance and potential healing power of attachment in psychotherapy:

The urge to keep proximity [to another] is to be respected, valued and nurtured as making for potential strength instead of being looked down upon, as so often hitherto, as a sign of inherent weakness.
                                                                   (Hofler & Kooyman, 1996: 518)

To further examine the ties between attachment and addiction, an overview of early attachment features by Parkes et al. (1993: 515) may be a valuable contribution.

Criteria of early attachment (Parkes et al., 1993)

1. Proximity seeking
2. Secure base effect
3. Separation protest
4. Elicitation by threat
5. Specificity of attachment figures
6. Inaccessability to conscious control
7. Persistence
8. Insensitivity to (even negative) experience with the attachment figure

As pointed out by Hofler and Kooyman in their 1996 article on attachment and addiction, Parkes’ criteria of early attachment also mirror a dependent relationship with substances. Substances can be seen as a surrogate secure base. In Julie Miller’s 2002 article, “Heroin Addiction: The Needle as Transitional Object”, she describes a client who experienced extreme childhood trauma and neglect as a result of her mother’s emotional dysregulation and preoccupations, who turns to heroin to repair the trauma of her past. In popular culture, drugs are often likened to transitional objects. The heroin dealer in Irvine Welsh’s Trainspotting is named Mother Superior, a friendly figure providing a drug that induces the comfort of a “warm hug” (Maté, 2008: 148) to the despairing. In John Lennon’s song written during his period of opioid dependence, the Beatles sang that happiness was a “warm gun, Mama”, possibly alluding to a heroin needle after use.

I need a fix ‘cuz I’m going down […] 
When I hold you in my arms /
And I feel my finger on your trigger /
I know nobody can do me no harm / 
Because happiness is a warm gun, Mama
                                                                                            (Lennon, 1968)

Self-defeating substance addiction and behaviours become reasonable when understood as a substitute for an absent parent (physically or emotionally) and the void created within the infant. When Ainsworth’s criteria of attunement, sensitivity and responsiveness (Holmes, 2001) for secure attachment are not present, the child will feel rejection from the attachment object, and internalise badness (Klein, 1946) from the parent that will stay with them for life. Addiction offers a short-term alternative that grows into a long-term issue. When attachment theory is utilised as a lens to understand addiction, it “offers a less pathologising approach to treatment” (Fletcher et al., 2015: 115).

Applying attachment theory – the therapeutic relationship

“Secure attachment liberates”
                                                  (Flores, 2001: 72, quoting Holmes, 1996).

The dominant factor in sustaining healthy psychotherapeutic process is a strong therapeutic relationship between client and therapist (Ardito et al., 2011). Since an individual coming to therapy is likely to be in emotional and psychic distress, they are unconsciously open to finding a new attachment relationship with the therapist (Hofler & Kooyman, 1996). A person’s “attachment system opens up during a crisis” (Flores, 2001: 72), and Alcoholics Anonymous among other interventions recognises ‘hitting bottom’ as a crucial time to work on recovery from addiction. Therapists should understand the importance of their role when working with addiction: through bonding and transference they may provide a parental substitute (Hofler & Kooyman, 1996), a secure holding environment and base for the client to begin to explore their world without reliance on substances.

Philip J. Flores suggested that attachment informed therapy “within the context of addiction should center on the therapeutic relationship and the transformative potential of human relationships” (Fletcher et al., 2015: 113). In order for the client to feel safe to develop a relationship, the therapist must hold boundaries in order to build trust. While forming secure attachment and being attuned to the client’s needs, the therapist must also respect their unique separateness, careful to also facilitate the individual’s autonomy. Because of the addicted person’s traumatic childhood, they may have dysfunctional care-eliciting behaviour that the therapist should be aware of and bring to the client’s attention (Flores, 2001). Once trust is established, the therapist can employ challenge into the relationship, a technique referred to as optimal frustration. Optimal frustration in the client is “a careful balance between affect release and affect containment”, a line that is particularly fragile while the client is at risk of relapse (Flores, 2001: 74). A patient approach and openness to listening to the trauma of the “shattered childhood[s]” (Darke, 2012: 660) lends the client a space to explore their pain, for the first time with support and empathy. Body psychotherapy is also an apt mode of addressing addiction leading to emotional dysregulation (Powers, 2017). Somatic interventions can assist the client in developing a strengthened mind-body connection, and learning to self-soothe in times of distress (Powers, 2017).

Once the individual has learned to securely attach to the therapist and begins to have their needs met, they can work on sustaining healthier relationships with those in their life. Adult attachment figures can be found in marriages, group therapy, family, and friend groups (Hofler & Kooyman, 1996), and can provide a strong support system for the client to lean on for emotional regulation, minimising the risk of relapse.

Group therapy – group as transitional object

Group therapy has been synonymous with addiction treatment since the advent of Alcoholics Anonymous groups and fellowships in 1935 (General Service Office of Alcoholics Anonymous, 2017). Although a modern approach to addiction treatment is multi-faceted, clients seem to derive a range of benefit from group therapy, especially when they engage towards the final stages of their treatment. Fletcher et al. stated in 2015 that a twelve-step group serves as a secure base for its members, fostering ‘nurturing and consistent relationships, which in turn facilitates a strong bond and attachment to the group’ (Fletcher et al., 2015). Since group therapy in any modality is intrinsically sociable, it is a valuable form of therapy for recovered addicts to engage in. “Since relationships can also be addicting, the addict and alcoholic must learn how to maintain healthy relationships within the group before they can establish them outside of the group”
(Flores, 2001: 79).

Yalom’s therapeutic factors for change in group members are fundamental processes for persons with addiction to encompass: (1) instillation of hope (2) universality (3) imparting information (4) altruism (5) corrective recapitulation of the primary family group (6) development of socialising techniques (7) imitative behaviour (8) interpersonal learning (9) group cohesiveness (10) catharsis, and (11) existential factors (Hook et al., 2008). This corrective environment can help clients to work through their ambivalence about relational “themes like dominance and submission and dependency and autonomy” (Flores, 2001: 76), in order to stimulate their confidence in forming and maintaining boundaried, supported relationships outside of the therapeutic setting.

Conclusion

“The childhoods of [substance] users are not incidental. They are core.”                                                                                     (Darke, 2012: 664).

The lens of attachment theory is invaluable for psychotherapists to gain insight and understanding into the lives of their addicted clients. Empathising with the client’s traumatic psychic struggle comes naturally when the therapist has an integrative framework to work from; in this case an understanding of the client’s unconscious need to attach, and how their desperation for secure attachment has led them into dependency with substances and behaviours. Rather than seeing addiction as a dark energy that affects depraved individuals, our task is to connect with the pain of rejection that substances are so effective at ameliorating, however short term the comfort.

Using Motivational Interviewing, the therapist can help the client to address their ambivalence around their drug use. Once denial and the seduction of the substance are managed, the client can progress into deeper long-term therapy work in a healthy therapeutic relationship. By striving to understand the meaning that a client’s particular addiction has for them, we create a space for the emotionally impoverished child to speak its truth, and be seen, heard, known, and held, their experience validated in our presence. Along with well-facilitated group therapy and supports in their daily life, lasting healing from addiction may be possible, and internal growth will continue. This approach must not be used in isolation, but part of a network of supports to assist the client physically, socially and spiritually.