Insecure Attachment and Drug Misuse among Women

Abstract

The relationship between attachment and gender is well researched in social work, as is the influence of insecure attachment on drug misuse. However, discussion of the interrelationship among insecure attachment, gender, and drug misuse is sparse in the social work literature, with contradictory findings. The attachment literature indicates that males and females exposed to the same stressful events may differ in their reaction to stressors and to insecure attachments. Some studies find that gender differences emerge in infancy, others argue that they emerge from middle school and onward. Some authors report that attachment differences may be related to the fact that parents tend to use more emotional language with girls than boys, while other authors report that female children are more prone to discuss their emotions openly than male children. Regardless of the causal direction, there seems to be agreement that attachment is influenced by gender and that insecure attachment can have unique consequences for girls and women that are heretofore understudied. This conceptual paper provides an overview of the relationships between attachment, drug misuse, and gender in an effort to advance our understanding of the role gender plays in drug misuse among women. Recommendations are also discussed for attachment-based assessment and treatment approaches that may benefit women who misuse drugs and their families.

KEYWORDS:

• abuse
• affect regulation
• attachment
• drug use
• gender
• insecure attachment
• trauma
• women

Drug misuse is a public health concern in many countries. According to the Substance Abuse and Mental Health Services Administration (Substance Abuse and Mental Health Services Administration (SAMHSA), 2014), 21 million people ages 12 and older in the United States suffer from a substance use disorder. The rate of drug misuse for males ages 12 and up was found to be almost twice as high as that of females. Drug-misusing males and females differ in their characteristics, risk factors, needs, biological response, psychiatric disorders, and barriers to treatment (Tuchman, 2010). Recent studies show that most women with substance use disorders experienced sexual, emotional, or physical abuse; 74% of women with substance use disorders reported sexual abuse, 52% physical abuse, and 72% reported emotional abuse (Covington, 2008).

Drug misuse is a very complex issue, one that is treated differently depending on the therapist’s perspective of the problem. Currently, the most popular theoretical explanation of drug misuse is the disease model, which views drug use as a lifetime disease with no cure (Cihan, Winstead, Laulis, & Feit, 2014). Attachment theory looks at drug misuse from a different lens, viewing it as a symptom of an underlying problem: one of self-regulation, formed by insecure attachments experienced during infancy and early childhood (Cihan et al., 2014). According to attachment theory, infants and children that experience insecure attachments and trauma are at greater risk of developing behavioral problems and substance use disorders that may continue into adolescence and adulthood (Godinet, Li, & Berg, 2014).

There are many studies (see Tronnier, 2015) that discuss drug misuse as an attachment disorder, yet there is little research concerning the connection between gender, attachment, and drug misuse (Tonnessen, 2014). John Bowlby, the originator of attachment theory, believed that attachment is essential for survival of all humans and therefore is equally important for boys and girls (Tonnessen, 2014), though for years the importance of gender difference as it relates to attachment was not specifically addressed. Until recently, most researchers assumed that the influence of attachment figures is universal and independent of gender (Pierrehumbert et al., 2009). However, recent research shows that there are gender differences in regards to attachment (Gloger-Tippelt & Kappler, 2016), which will be discussed further herein.

This paper will introduce the reader to the differential effects that early insecure attachment experiences have on the development of drug misuse for boys and girls. Understanding gender-specific connection is essential for treatment of drug use disorders, as the way clinicians understand the addiction process will affect the way they address treatment and research (Tronnier, 2015).

ATTACHMENT THEORY

Attachment theory refers to one’s biologically rooted tendency to create strong emotional bonds with their caregivers in the first years of life (Wyrzykowska, Głogowska, & Mickiewicz, 2014). The need for warmth, security, and connection is built-in and essential for the infant’s survival (Bowlby, 1958). Each child has an attachment behavioral system that in times of distress is activated, prompting the child to seek an attachment figure for support and comfort. When the child’s needs are sufficiently met, the system is less activated and the child is able to move away, both physically and metaphorically, from the caregivers in order to explore other relationships (Wang & Stalker, 2016). When the child does not receive the adequate response needed from the caregiver, insecure attachment styles are formed. Each child develops his own set of expectations, or internal working models, in regards to their caregivers’ responsiveness and availability to their needs (Winham et al., 2015). These models are internalized by the child and develop into schemas for how the adult sees him- or herself and interpersonal relationships in the future (Winham et al., 2015).

Attachment theory refers to three attachment styles resulting from insecure attachments: preoccupied, dismissing (avoidant), and disorganized styles. Preoccupied attachment style develops as a result of caregiver inconsistency. With this attachment style, one is impulsive, feels unworthy, constantly seeks approval, and is dependent on others. Dismissing (avoidant) attachment style develops as a result of early experiences of rejection. In this attachment style, one denies the need for connection with others and suppresses his feelings. Finally, disorganized attachment style develops as a result of early trauma, abuse, neglect, or loss, leaving the individual feeling like a victim and prone to perceive relationships as dangerous (Wang & Stalker, 2016). Attachment styles are understood to be consistent throughout childhood and adulthood. However, research suggests that traumatic events increase the likelihood that a child develops insecure attachments even if they had a secure attachment style prior to the traumatic events (Kries, Gillings, Svanberg, & Schwannaur, 2016).

THE INFLUENCE OF GENDER ON ATTACHMENT

Current attachment research is expanding across the life span. Bowlby (1979) did not consider gender as a factor that contributes to attachment style, since he believed that a secure attachment is a must for any human being, no matter the gender. Thus, most researchers following Bowlby have assumed that the imprinting influence of attachment figures is universal in infancy and independent from gender (Gloger-Tippelt & Kappler, 2016). However, recent studies show gender differences in attachment styles. While some believe that gender differences emerge in infancy, others argue that they emerge as children get older (Del Giudice & Belsky, 2010).

Literature indicates that males and females that are exposed to the same stressful events may differ in their reaction to stressors and to insecure attachments. Studies have found gender differences among infants and small children in high-risk families. Female infants at risk have been shown to be more successful in controlling and suppressing expression of fearful affect, while male infants at risk tended to display negative affects more openly (Chaplin & Aldao, n.d.). In a study conducted by Tonnessen (2014), girls were almost twice as often securely attached as compared to boys, while boys were twice as often categorized as avoidant and three times as often categorized as disorganized. Insecurely attached boys tend to engage in more aggressive behaviors and react with action behavior and behavioral problems in response to stressors, while insecurely attached girls tend to please others (David & Lyons-Ruth, 2005). Thus, boys’ and girls’ responses to stressors differ: boys tend toward “fight or flight,” while girls tend toward “friend and befriend” (David & Lyons-Ruth, 2005). Some researchers believe that sex differences in insecure attachment emerge only from middle childhood, i.e., from age seven and on, with boys showing more avoidance behavior and girls showing more anxiety (Del Giudice & Belsky, 2010). Boys with insecure attachment are also observed to present more disorganized behaviors than girls, such as loss of control, violence, and destructiveness. Typically, girls show more internalizing behaviors while boys show more externalized behaviors (Kosiak, 2013). Perhaps as a consequence, boys in general are more often classified with insecure and disorganized attachment (Tonnessen, 2014).

Several studies from across the world show evidence that there are gender differences in attachment. Pierrehumbert et al. (2009) compared 10 community samples from five countries and found more attachment security in girls’ narratives and more disorganization in boys (Tonnessen, 2014). Evidence for gender differences in this direction is also provided from studies of 10-year-old children from Israel (Granot, 2001) and studies of 6 year olds from Hungary (Gervai et al., 2007). Hungarian girls’ attachment narratives were classified more frequently as secure; boys were four times more likely to be classified as disorganized. Similar narrative themes and classification have been observed in children from the US (Bretherton & Page, 2004) and Germany (Gloger-Tippelt & Koenig, 2016). Gender differences in regards to attachment were reported among families in community samples as well as families in high-risk samples. Zaman and Fivush (2013) present evidence showing that females talk more about emotions compared to males in the context of family dialogues. They found that across cultures, when talking to their children aged 3.5–7 years, both mothers and fathers used more emotion words with daughters than with sons. In Western countries, mothers were shown to talk more to girls about emotional events and about the causes of such emotions for the child (Zaman & Fivush, 2013). This may suggest that gender differences in attachment result from early socialization. However, it has also been suggested the causal direction might be opposite: daughters might be more interested in talking about emotions than boys, which may elicit more social conversations with the parents. In summary, there is evidence from attachment research to suggest that gender differences do exist and result in different behaviors and reactions to stress among females versus males.

DRUG MISUSE AS AN ATTACHMENT DISORDER

There is research examining behavioral outcomes for insecurely attached individuals throughout the social work literature, particularly related to drug misuse. In the 1970s, Edward Khantzian and David Duncan developed the Self-Medication Hypothesis (SMH), in which they claim that drug misuse can be conceptualized not as pleasure-seeking, but rather as a desire for contact and connection. More recent studies have found that those who misuse drugs significantly differ from non-users in attachment style and its dimensions and also differ from non-users in their ability to cope with traumatic events (Wyrzykowska, Glogowska & Mickiewicz, 2014). Further studies support the correlation between traumatic experiences and drug misuse (Kreis, 2016).

The vulnerability to drug misuse among those with histories of interpersonal trauma has been linked not only to compromised abilities to form healthy attachments but also to a decreased capacity for self-regulation (Flores, 2004; Khantzian, 2003). Vulnerability to misuse drugs is understood in the literature as resulting from an exposure to drugs in combination with the inability to tolerate or understand one’s own feelings (Fletcher, Nutton, & Brend, 2015). Khantzian (2012) explains that drug misuse should be viewed as a self-regulation disorder in which individuals self-medicate in order to compensate for their limited capacity for healthy self-regulation.

The skills of knowing how to regulate feelings and behavior are essential for survival, and modern attachment theory claims that the ability to self-regulate arises out of the caregiver-infant relationship (Schore & Schore, 2008). Attachment is the emotional bond the child and the caregiver create, based on the child’s needs. Through emotional interpersonal bonds, people learn how to take care of themselves and of others. When attachment security is compromised and insecure attachments are formed, the ability to develop affect regulation may be compromised (Kreis et al., 2016), and individuals who struggle with developing intimacy and closeness with others may seek out another method in which to self-soothe in times of distress.

Flores (2004) referred to drug misuse as an attachment disorder. Individuals that misuse drugs often lack the ability to recognize feelings, to develop a stable sense of self, to maintain comfortable relationships, and to develop adequate behavioral control, especially concerning self-care. Thus, a relationship with drugs can become an attachment, which acts as both an obstacle to and a substitute for interpersonal relationships (Flores, 2004). Because these individuals have an inability to recognize and regulate their own feelings and sense of self, they may act as though they do not need close interpersonal relationships. Such disengagement from self and others can produce distress and create a further reliance on substances in place of what would be healthy connection to and reliance on attachment relationships (Khantzian, 2012). A drug can therefore create the feeling of having a secure base, and addictive behaviors can be understood as misguided attempts at self-regulation (Flores, 2004). Drug misuse thus in a sense shelters the individual from relational vulnerability, becoming both the solution to and the consequence of an individual’s impaired ability to develop and maintain healthy attachments.

In accordance with this theory of drug misuse as an attachment disorder, Padykula and Conklin (2010) advocated for treatment that addresses attachment traumas. An attachment trauma can be any interruption in one’s primary attachment relationship, such as the experience of neglect, abuse, or loss. The experience of attachment trauma can create deficits in an individual’s capacity for emotional regulation, causing the individual to attempt to self-regulate by misusing drugs (Fletcher et al., 2015). Trauma survivors may also abuse drugs and avoid close interpersonal relationships in attempts to manage negative and intrusive memories, which are a hallmark symptom of complex trauma and posttraumatic stress disorder (Fletcher et al., 2015).

FACTORS CONTRIBUTING TO THE DEVELOPMENT OF DRUG MISUSE IN WOMEN

According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2015), 15.8 million women (or 12.9%) ages 18 or older have used illicit drugs in the past year. The rates of misusing drugs among female adolescents and adults are also persistently increasing in the last decade (SAMSHA, 2015). Women with drug use disorders differ from men with drug use disorders in many aspects, including patterns of use, drug choice, and progression of drug dependence (Stevens, Andrade, & Ruiz, 2009). Several demographics and clinical differences in connection to gender have been identified and will be reviewed below.

Women use more legal drugs, especially prescription drugs, generally using multiple drugs and combining a prescription drug with other drug types, and most women’s first drug of choice is alcohol (Tuchman, 2010). Women are also more likely to initiate drug misuse at a young age (9- or 10-years-old). When women initiate drug misuse at an older age, on average between ages 30–40 years, this is often as a result of relationship stressors such as divorce or separation (Doweiko, 2015). As women with drug use disorders may lack family or social support systems, they are prone to misuse drugs alone and in their home. Women with drug use disorders also report high levels of shame connected to the way others view them and to the way they view them self, as there is a greater social stigma for women that misuse drugs than for men (Doweiko, 2015; Kreis, Gillings, Svanberg, & Schwannaur, 2016). Thus, gender-specific constructs and gender-role expectations are internalized and guide women’s feelings of self-worth.

There is also a difference between men and women in regards to the physiological response to drugs. Studies show that women use smaller doses of drugs, for shorter periods of time, but the progression towards dependence is also shorter (Straussner, 2014). In addition, women are at a higher risk for hypertension, anemia, digestive system disturbances and gynecological complications.

While men are more likely to initiate drug misuse as a response to drug availability and external variables such as school, poverty, and peer groups, women have been shown to be more likely to initiate drug misuse as a reaction to issues in the family life, such as sexual, emotional, or physical abuse, and divorce (Brady, Back, & Greenfield, 2009). Studies suggest that women who misuse drugs tend to have grown up in families characterized by familial conflict, substance abuse, and domestic violence, which places women at higher risk for abuse, neglect, and behavioral problems (Sánchez-Queija Oliva, Parra, & Camacho, 2015). Harsh parental discipline is also associated with higher levels of drug misuse among women. Strong family bonds are associated with lower rates of drug misuse for both genders, while low parental attachment correlates more highly with smoking, drinking, and drug misuse among girls than among boys. Low parental monitoring and concern as well as an unstructured home environment are strongly correlated with drug misuse for women.

Both men and women are at a higher risk of misusing drugs if they have a family history of addiction, but studies show that having a family history of addiction is more common for women that misuse drugs than for men (Brady et al., 2009). Women tend to have greater responsibility for the family of origin, taking care of the emotional and physical needs of the family members. As a result, a woman’s drug misuse may be destructive to the family in distinct ways from that of a man with a drug use disorder (Tuchman, 2010).

It is well documented that while men with drug use disorders exhibit more antisocial behaviors and tend to become involved in criminal activity, women who misuse drugs are more likely to experience affective disorders and to be involved in minor issues with the law (Tuchman, 2010). The majority of women who misuse drugs suffer from comorbid psychiatric disorders, such as posttraumatic stress disorder (PTSD), as well as anxiety and major depression, which are shown to be related to childhood sexual abuse and intimate partner violence (Pape, & Sarabia, 2014). In studies of comorbid drug misuse and psychiatric diagnoses, women were found to have higher rates of major depressive disorder, anxiety disorders, eating disorders, and posttraumatic stress disorder. The frequency rate of depression among women who misuse drugs is remarkably high.

Studies also show that for women, primary depressive disorder diagnoses often predate the drug misuse. Finally, the number of suicide attempts among women with drug use disorders is higher than for men with drug use disorders (Pettiani & Plebani, 2009).

Studies show that a majority of women with drug use disorders have suffered several sexual abuse experiences over the lifespan, also known as complex trauma (Hein, 2009). Most women initiate drug misuse in response to a specific traumatic event that has occurred in their lives, frequently incest or rape (Covington, 2008). In such cases, the woman often does not have a previous history of misusing drugs or alcohol prior to the traumatic event. Research indicates that at least 70% of women who report misusing drugs also report having been abused sexually before the age of 16 years (Sartor et al., 2013). The drug is used as self-medication, a survival tool that helps the woman cope with the intolerable pain that was caused by the trauma, acting as a defense that helps deny the intolerable feelings of helplessness, fear, rage, and shame that the woman feels as a result of the trauma (Gur, 2008).

Women are also more likely than men to be in relationships with partners who misuse drugs, who may introduce them to drug misuse and may be the main suppliers of the drugs (Kreis et al., 2016). Women often identify traumatic relationships and relationship problems as a cause of drug misuse. Women’s motivation and sense of identity is often based on relationships, as is the way they see themselves in regards to others. When women experience abuse, neglect, and trauma, they may feel confused and disconnected from self and others (Gur, 2008) and turn to drugs as a substitute for relationship.

DRUG MISUSE, ATTACHMENT, AND GENDER

The differential effect that early insecure attachment experiences have on the development of drug misuse for boys and girls has been a neglected topic in the literature, and the limited knowledge regarding the link between insecure attachment, drug misuse, and gender is often inconsistent (Asscher, Put, & Stams, 2015). Researchers have reported that the consequences of maltreatment play a greater role in the development of delinquent behavior in females than in males (Foy, Ritchie, & Conway, 2012). In a recent study, Winham et al. (2015) examined the role attachment plays between childhood victimization, psychological distress and substance misuse among 406 women on probation who have a history of childhood victimization. It was shown that childhood victimization did not predict drug misuse, but attachment did. This study also found that insecure attachment influences a woman’s image of herself and her relationship. Insecure attachments could lead to difficulties in responding to stressful life situation, to developing depression and posttraumatic stress disorder, and to misusing drugs.

Some studies show that child abuse increases risk for drug misuse for females and not for males. Lansford et al. (2007) found that there is a link between parental physical abuse in the first five years of life and drug misuse for females but not for males. Widom, Czaja, and Dutton (2008) found support for the idea that insecure attachments could predict drug misuse in early adulthood for females, but not for males, with females who misuse drugs reporting more maltreatment as children than do males. Fagan & Wright (2011) found that interpersonal violence exposure increased the likelihood of drug misuse among females but not males, and interpersonal violence exposure predicted an increased frequency of drug misuse among females but not males. Furthermore, a study of 1,030 adult male prisoners and 500 adult female prisoners in Texas revealed significant gender differences in childhood and adult maltreatment and drug misuse. Female inmates also report significantly more maltreatment as children than do male inmates (D’Orio, Thompson, Lamis, Heron, & Kaslow, 2015). A more recent study by Kries et al. (2016) compared male prisoners with female prisoners and found higher levels of lifetime trauma experiences and emotional and mental health problems than male prisoners and women in the general population. The women in this study shared similar patterns: all began misusing drugs in their teens; all had dysfunctional parents and suffered early traumatic experiences that included abuse, neglect, rejection, abandonment, and parental drug misuse; and all suffered from insecure attachment styles that were a result of unmet needs for love, security, safety, and connection (Kries et al., 2016). These findings taken together suggest that adverse interpersonal relationships may be central to substance misuse and drug-related offending in some women, and may involve underlying relational psychological processes including complex trauma, insecure attachment, and shame. Drug misuse may thus develop as an attempt to cope with the pain of disconnection (Kries et al., 2016).

IMPLICATIONS OF ATTACHMENT FOR TREATMENT

As discussed earlier, insecure attachment experiences in childhood may be the central cause for women’s and girl’s drug misuse (Kries et al., 2016). In several studies, women reported viewing connectedness to others as playing a significant role in their process of drug misuse and recovery. Considering the implications of insecure attachments on drug misuse, psychological distress, parenting and more, it is critical for attachment-based treatment to be considered in assessment, prevention, and treatment of women who misuse drugs (Winham et al., 2015).

Attachment-based therapy is relationally focused and includes the modalities of both individual and group therapy. It provides an opportunity for contact and a framework that supports the healing nature of the human connection (Ruisard, 2016). The focus of attachment-based therapy is on creating secure attachments and helping women develop the ability to form positive and strong bonds (Potter-Efron, 2006). The foundation of attachment-focused therapy is the therapist-client dyad. The therapeutic relationship fosters positive change. The therapist becomes an attachment figure, providing a secure base that was missing from the client’s early life. This dyad engages in direct right- to- right brain affective communication, stimulating and encouraging growth in the areas of the brain that were neglected during early development (Schore & Schore, 2008). Research suggests that as secure attachment experiences increase, so does an individual’s capacity for a curious, optimistic, and positive approach to adversity, which, in turn, can strengthen cognitive, emotional, and behavioral responses to stressful situations (Mikulincer & Shaver, 2007).

It is essential that attachment styles and relational experiences be assessed as treatment is accessed. Accordingly, if attachment insecurities are noted, treatment strategies need to be employed to target individual’s attachment histories and current adult attachments (D’Orio et al., 2015). Available assessment tools to evaluate attachment include the Revised Adult Attachment Scale (Collins & Read, 1990) and the Experiences in Close Relationships Scale (Brennan, Clark, & Shaver, 1998). Information received from the assessment can help clinicians become attuned to the client’s relational style, history of traumatic experiences, and defenses against emotional wounds (Wang & Stalker, 2016).

Since women seem to be empowered through connections (Gur, 2008), women with drug use disorders may greatly benefit from group therapy in a single-gender group that uses an attachment-based approach. Attachment approaches view drug misuse as an attempt to or substitution for satisfying needs for connection. Group treatment can create an opportunity for satisfying relationships, which the individual must achieve in order to give up their need to misuse drugs (Flores, 2004). Of particular importance is the ability for women to experience stable environments and emotional connections that provide a secure base for strengthening their capacity to regulate emotions (Marmarosh & Tasca, 2013). Such environments provide safe places for emotional regulation that can reduce the need to manage emotions through drug misuse or other high-risk behaviors. Studies show that the more secure attachment experiences the woman has, the more she will be able to develop a positive approach to self, which can strengthen her responses to stressful situation on cognitive, emotional and behavioral levels. The therapy group may serve as a safe base for the women, model secure attachments, and teach them how to create healthy relationships (Winham et al., 2015). Such an approach may be particularly helpful for women in the criminal justice system and helping them to address underlying factors of drug misuse, including treatment for trauma and mental health problems (Welch-Brewer & Roberts-Lewis, 2011).

Strengthening secure attachment is also viewed as an effective prevention strategy among girls that are at risk for future drug misuse (Kries et al., 2016). This involves helping them to develop coping skills and increase resilience, as well as assisting the girl’s primary caregivers in providing a warm, supportive environment and strengthening their attunement and sensitivity to the girl’s needs. Early complex trauma exposure impacts attachment development, with insecure or disorganized attachment styles as a common consequence (Kries et al., 2016), consequently, routine screening for exposure to traumatic events is warranted in all mental health assessments with children and adolescents. When trauma is present, evidence-supported treatments should include attachment-based, psychoanalytic, and cognitive– behavioral approaches that emphasize attention to the traumatic exposure, caregiver involvement, and resilience (Winham et al., 2015).

CONCLUSION

The question of how insecure attachment styles coexist with or precede drug misuse among women remains open. Studies focused on the association between gender, insecure attachment, and drug misuse are still limited. Results do suggest that there is a correlation between drug misuse, insecure attachment, and gender, though the underlying psychological mechanism remains unclear. Further research involving protective factors in connection to women’s drug misuse is needed. If further findings support the connection between insecure attachment, drug misuse, and gender, attachment-based interventions are suggested as an approach to reducing drug use disorders among women and girls. Moreover, if attachment styles and social support provide resilience against problematic drug misuse among women, preventive interventions should be developed and enhanced specifically in this high-risk population. Future research needs to examine interpersonal protective factors that may mitigate drug misuse among women. These protective factors may be excellent targets for intervention.

Acknowledgement

This writer would like to thank Dr. Shulamit Straussner for her supervision and support throughout the process of writing this paper.