Sunday, April 14, 2013

Attachment, development, abuse and addiction: a personal theory

The population with which I work with consists of teens and young adults with substance use issues. In nearly all cases, I also work with the client's parents. When possible, siblings and significant others are included as well. My role is that of counselor, therapist, and case manager. Clients are generally middle or upper-middle class, white, and male, though there is much variation. A significant majority of the clients suffer from symptoms of mild mood disorders, especially mild depression or dysthymia, and/or ADHD (DSM-IV TR, 2000). Most of my clients and their families are above average intelligence, which can be both an asset and hindrance when performing interventions.
Attachment theory informs my practice more than any other theory. In my research, I have found that attachment theory seems to have the firmest roots in empiricism when compared to other theories of personality. I find attachment theory optimistic, multi-level practice friendly, and congruent with my personal experiences of recovery.
In the absence of secure attachment, and more specifically a soothing internal working model, people are much more vulnerable to developing pathological self-soothing behaviors (Cozolino, 2006). Seeking intoxication is one of these affect-regulating behaviors. If I am able to build a soothing internal working model in my clients, I believe they gain resilience and are more likely to recover from their issues. As a clinician treating adolescents and young adults with substance-related disorders, it has become increasingly apparent that affect dysregulation, and a related difficulty with turning to others for emotional soothing, contributes to the onset and severity of drug use, continued use, and relapse. Affect regulation must be a primary issue of focus in treatment for sustained recovery. The challenge for the user is learning to recognize and experience their own emotional states, understand their need for support, build social connection, and trust that they can turn to healthy people to regulate emotions instead of turning to drugs, drug dealers and drug culture.
Over the past 60 years, attachment theory has shown that when children are raised by parents who are warm, nurturing, reflective, consistent and attuned to their child's needs, it not only builds their psychological presentation of affect regulation, but shapes the brain as well (Seigel, 1999; Levy, 2000; Schore, 2003). Attachment theory began with the work of John Bowlby and was advanced in the 1960s by Mary Ainsworth through her application of the empirical process to the theory. Her work employed naturalistic observation to study of the relationship between a mother and child. The dyads were studied when together, when separated and most importantly during reunion. This process was dubbed the “strange situation.” Since publication, Ainsworth's work has been one of the most reviewed and replicated studies in developmental psychology. The resulting work has classified attachment into various well-substantiated categories: secure, anxious-ambivalent / preoccupied, dismissive / avoidant, and disorganized (Armsden & Greenberg, 1987; Ainsworth,1978; Cassidy & Shaver, 1999). The attachment style of the child can be predicted with 80% success by assessment of the parents' attachment styles (Siegel & Hartzell, 2003)
As a pre-teen enters the adolescent phase of life, powerful internal struggles emerge. These years encompass many social changes as well as internal changes (Cozolino, 2006). Change, whether good or bad, creates stress. Adolescence is a time of significant change. During this time of change, the brain is reorganizing itself during its last period of neuronal growth and connection. Then myelination starts to occur in early twenties, a process where many major pre-existing neural connections become more solidified (Giedd et al 1996; Pfefferbaum et al 1994; Spear, 2000; Yurgelun-Todd et al 2002). Changes which take place prior to myelination, especially earlier in childhood, have profound effects upon personality and attachment over the lifetime (Siegel, 1999; Cozolino, 2006).
For my clients, the adolescent years may be a naturally occurring strange situation. During the elementary school experience, most children are with the same students and teacher each day. Thoughts of romantic attachments have not yet occurred, and social skills used for connecting with others are fairly simple. Middle school and high school can be a time where children are with different peers and different teachers four to six times per day, as they move between new classrooms to learn new subjects. Peers start to form social cliques, romantic feelings begin to arise, and social skills become sophisticated to match relationships which are becoming increasingly complicated. For the insecurely attached teen (preoccupied, avoidant, or disorganized), this can elicit a heightened state of anxiety and a taxing of affect-regulating resources.
In 2007, a large study of teen attitudes found that they were significantly more likely to think that their peers use drugs to relieve pressure and stress (73%) than they were to use drugs solely as a means to have fun (26%). An accompanying survey of parents’ attitudes showed a severe disconnection with the experience of their children – only 7% of parents believed that teens might use drugs to cope with stress. This research highlights a societal misattunement between caregiver and child (PATS, 2007). My practice with families in counseling and in the community, giving talks at parent forums, has confirmed this research over and over. When parents are too busy or otherwise misinformed about their teens' stressors, their teens will adapt and find other ways to cope. Those other coping strategies may be healthy – such as sports, hobbies, and having relationships with other teens or adults. Far too often, however, teens turn to drugs. Along with drugs comes drug culture, which nurtures the experience of misattunement to the outside world. Helping clients break the bond with drug culture is as difficult as breaking the bond to intoxication, especially when normal teen culture is accepting and often admiring of drug culture.
Researchers have shown that attachment is related to peer relationships and peer competence across developmental periods (Elicker, Englund, & Sroufe, 1992). Popularity, aggression, self-esteem, and the emergence of mental health issues such as depression all arise during adolescence, and have been correlated with attachment style (Armsden & Greenberg, 1987; Cohn, 1990; Nada Raja, McGee, & Stanton, 1992; DeMulder, Denham, Schmidt, & Mitchell, 2000).
The parent-child relationship is also correlated with peer social skills in preschoolers (Pianta, Nimetz & Stanton, 1997). Cassidy, Kirsch, Scolton, and Parke (1996) found that children securely attached to their mothers more often believe that their peers have positive intent in ambiguous situations, which supports the notion that early attachment experiences for the child with the caregiver cast forward far reaching implications for peer interactions. Freitag et al (1996) found that secure attachments may foster social competence during middle childhood, likely impacting the quality and security of friendships. Self-reports of security with one’s mother have been shown to relate to fifth graders’ acceptance by their peers (Kerns, Cole, & Klepac, 1996). Peer competence has also been shown to be mediated by attachment in adolescents (Allen et al., 1998).
Through early interactions with caregivers, children internalize and organize their understanding of relationships. Attachment bonds are not only important for general well being, but build the template and expectation for all relationships across the lifespan. As early as infancy, children have mental representations of their attachment figures, and they construct ideas and expectations for relationships with their attachment figures. Bowlby called this the internal working model (IWM) of attachment. Bowlby believed that starting in infancy a child internalizes patterns of relating to people, generally the parents, and forms an idea of how to relate to others based on these representations (Waters et al., 2000). In more recent history, attachment has been characterized by many researchers as a structure which shapes the person's interpretation of the nature (and safety) of sensations, perceptions, memories, emotions, thoughts and behaviors. Over time, attachment experiences and genetics interact to create most aspects of personality, and in unhealthy situations, personality disorders (Cozolino, 2006).
Biologically, parts of the dopamine and opiate systems become highly activated during the attuned experience between parent and child. This pleasurable experience of attunement makes up a significant portion of the ongoing attachment between two people. Additionally it sets the stage for a generalized style of attachment, used to soothe a person's uncomfortable emotions. If an infant or young child turns to others for emotional soothing, but is left alone emotionally, the child experiences shame, a painful and aversive experience. As the brain adjusts itself to more easily use the systems which are used the most, the development of the dopamine and opiate systems used for emotional regulation can be stunted by shame (Schore 2003, Siegel 1999). Avoiding others when affect is dysregulated becomes reinforced.
When people use drugs, the dopamine and opiate systems are activated, among other areas of the brain (Wise, 1996). Since these are the same systems operating during parent child bonding in the early formative years of life and thereafter, it is not a jump in logic to assume that drugs become a substitute for healthy co-regulation. Much research has highlighted the risks and protective factors to developing substance-related issues and other psychological problems (Corcoran & Walse, 2010). From my research and work with young drug abusers, I have come to believe that the most crucial risk or protective variable is the attachment style and attachment experiences of the client. Aside from the necessary, but sometimes menial, task of denial-breaking, the most important intervention for recovery is helping the client have healthy attachment experiences which they can generalize to the outside world.
It is the view of our counseling group that any substance use is potentially harmful, as teens brains are developing. Teens brains are naturally biochemically off-balance, and completing the developmental tasks of adolescence rights the imbalances. Intoxication can disrupt the course of development because it temporarily produces intense positive feelings which would otherwise come in lower yet sufficient levels from meeting developmental tasks (Daily & Cassidy, 2010). Thus, part of the program involves setting firm limits around drug use (including alcohol) and enforcing consequences. As limit-setting is a necessary component of treatment which helps clients become clean, occasionally families are therapeutically discharged for being unable, despite much counseling, to set appropriate limits on the child's substance use.
Clinicians unfamiliar with teen substance use have argued that this is damaging to the attachment between therapist and client, and therefore unethical. I was skeptical of this practice when new to the group. With more experience, I came to see that growth is nearly impossible while a client is active in a relationship to intoxication. A relationship to intoxication is, in its nature, a relationship to being disconnected from real emotion because drugs mimic emotions. Even though it is disruptive to the attachment to enforce strict boundaries, it is the only real option to lay the groundwork for progress. Therapeutic discharge can also help break parents' denial that their child is in danger and distress.
Another common ethical ethical issue which outside clinicians often inquire about regards the protection of confidentiality when our clients are below the age of majority. Clinicians wonder if it is necessary to break confidentiality and inform the client's parents that they are using drugs, which are harmful and potentially life-threatening. In substance abuse treatment, the primary goal is to help the client see they are in a problematic relationship to intoxication. The method for uncovering the relationship must be tactful, gentle, and at the right pace for the client. Their relationship to intoxication is so important to them, and creates such intrapersonal volatility, that any other method might critically wound the therapeutic relationship and make treatment minimally effective. Breaking confidentiality is only reserved for imminent threat of death or irreversible or severe harm. After individual treatment with the client has progressed successfully for a few months, clients are strongly encouraged to share all of the confidential information with their parents, and referred to inpatient treatment if unable to do so. This way, we can build trust with the teen and their parents, while intervening in denial.
It is worth noting that trauma dysregulates the endorphin and dopamine systems. The extreme stress associated with trauma produces a release of endorphins to reduce hyperarousal, anxiety and pain (Demetral, 2010). Over time, the endorphin system can become overworked and under-replenished, and other neurotransmitter systems are impacted. Stress suppresses the release of dopamine, reducing the feeling of reward for positive behaviors (Demetral, 2010; Cozolino, 2006). It is no surprise that trauma tends to be associated with an increased use of alcohol and other drugs. Secondary trauma is also associated with increased substance use, leading one to question the relationship between parental trauma and child substance use disorders (Straussner & Phillips, 2004).
Counter-transference can be an ongoing battle when one's primary practice theory is attachment. I am fully aware that I must enter into an individualized attuned relationship with each of my clients. Attunement involves matching my body's physiology to that of my client. Millions of years of evolutionary programming have culminated in a powerful ability for humans to read each other. My clients may not always to able to verbalize it, but when I am out of sync with them, they feel it. Emotion is a speedy system binding together various perceptions into a visceral knowledge and decision engine.
It is quite rare that I feel personally disrespected or harmed by clients while practicing social work. I learned a long time ago that people act based upon their own motivations and internal forces, of which I have relatively little influence. However it takes a great deal of courage and resilience to be with clients while they review difficult experiences and emotions. I feel as though I have aged a great deal since beginning this work, because of the anxiety and stress which arises from constant attunement to dysregulated individuals and families. Becoming sufficiently centered has been difficult given the whirwind of readings, assignments, case management and therapy inherent to graduate school. I can physically feel my stress level recede and my creativity, drive and excitement increase as I begin the transition out of direct practice.
The most common form of counter-transference I experience is an aversion to being present with clients' emotions. This is likely an impediment to progress on many levels. I have been feeling ever more worn out and less able to cope with clients emotions as the semester has progressed. Should I do direct practice in the future, I will have to remain diligent at self-care when outside of the therapeutic setting. At this point I have no plans to return to direct practice, which affords me much relief. I have profound respect for those human beings who are able to maintain while doing direct practice as a career.
I have voluntarily been in therapy for many, many years (compared to my age), paying out of pocket in my late teens and early twenties. Also I have been actively involved in twelve step communities, which value personal growth above anything else. I think my experience has given me an advantage compared to most of my colleagues in being able to minimize the effects of issues which may create problematic counter-transference.
Corey, Corey & Callahan (year) provide a guide for new therapists in managing their personal and professional selves. At one point or another, I have experienced nearly every problem outlined, from wanting clients to make progress to decrease my own sense of urgency, to being mildly inmeshed with clients, to feeling inadequate when clients do not make progress, and many more. Overall I manage these issues well and each one provides an opportunity for growth and lively discussion with colleagues. Recently, burnout has caused me to reduce my client load. This is likely due to having Corey, Corey & Callahan's “Most Stressful Client Behaviors for Therapists” occur as the norm in my work at Recovery Happens. I look forward to moving on, and doing good elsewhere.


Ainsworth, M. D. (1978). Patterns of attachment: a psychological study of the strange situation. Hillsdale, N.J.: Lawrence Erlbaum Associates.

Armsden, G. C., & Greenberg, M. T. (1987). The inventory of parent and peer attachment: Individual differences and their relationship to psychological well-being in adolescence. Journal of Youth & Adolescence, 16(5), 427-454.

Cassidy, J., & Shaver, P. R. (1999). Handbook of attachment: theory, research, and clinical applications. New York: Guilford Press.

Cohn, D. A. (1990). Child-mother attachment of six-year-olds and social competence at school. Child Development, 61, 152-162.

Cassidy, J., Kirsch, S. J., Scolton, K. L., & Parke, R. D. (1996). Attachment representations of peer relationships. Developmental Psychology, 32(5), 892-904.

Corcoran, J., & Walsh, J. (2010). Clinical assessment and diagnosis in social work practice(2nd ed.). Oxford: Oxford University Press.

Corey, G., Corey, M. & Callahan, P. (2007). Chapter 2: The counselor as a person and as a professional. Issues & ethics in the helping professions. Australia: Thomson Brooks/Cole.

Cozolino, L. J. (2006). The neuroscience of human relationships: attachment and the developing social brain. New York: Norton.

Daily, J. J., & Cassidy, J. (2010, February 26). Understanding & Treating the Opiate Addict: Buprenorphine, Attachment & Interpersonal Neurobiology. Lecture presented at University of San Francisco, Sacramento.

Demetral, D. (2010). The psychobiology of stress and the etiology of anxiety disorder(s). From Social Work 223 DSM: California State Univeristy, Sacramento; Fall 2010. Unpublished manuscript.

DeMulder, E. K., Denham, S., Schmidt, M., & Mitchell, J. (2000). Q-sort assessment of attachment security during the preschool years: Links from home to school. Developmental Psychology, 36(2), 274-282.

DSM-IV-TR: Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). (2000). Washington DC: American Psychiatric Association.

Elicker, J., Englund, M., & Sroufe, L. A. (1992). Predicting peer competence and peer relationships in childhood from early parent-child relationships (R. D. Parke & G. W. Ladd, Eds.). In Family-peer relationships: modes of linkage (pp. 77-106). Hillsdale, NJ: L. Erlbaum Associates.

Freitag, M. K., Belsky, J., Grossmann, J., Grossmann, K., & Scheuerer-Englisch, H. (1996). Continuity in parent-child relationships from infancy to middle childhood and relations with friendship competence. Child Development, 67(4), 1437-1454.

Giedd, J. N., Snell, J. W., Lange, N., Rajapakse, J. C., Casey, B. J., Kozuch, P. L., Rapoport, J. L. (1996). Quantitative magnetic resonance imaging of human brain development ages 4-18. Cerebral Cortex, 6, 551-560.

Kerns, K. A., Klepac, L., & Cole, A. (1996). Peer relationships and preadolescents' perceptions of security in the child-mother relationship. Developmental Psychology, 32(3), 457-466.

Levy, T. (2000). Chapter 2: Treating ADHD as attachment deficit hyperactivity disorder. Handbook of attachment interventions, 27-63. Academic Press: San Diego, CA.

Nada Raja, S., McGee, R., & Stanton, W. R. (1992). Perceived attachments to parents and peers and psychological well-being in adolescence. Journal of Youth and Adolescence, 21(4), 471-485.

The Partnership Attitude Tracking Survey (PATS).  Teens 2007 Report; Released August 4, 2008;

Pianta, R. C., Nimetz, S. L., & Bennett, E. (1997). Mother-child relationships, teacher-child relationships, and school outcomes in preschool and kindergarten. Early Childhood Research Quarterly, 12, 263-280.

Pfefferbaum A., Mathalon D. H., Sullivan E. V., Rawles J. M., Zipursky R. B., Lim K. O. (1994). A quantitative magnetic resonance imaging study of changes in the brain morphology from infancy to late adulthood. Archives of Neurology. 51, 874-887.

Schore, A.N. (2003).  Affect dysregulation and disorders of the self. New York: W.W. Norton.

Siegel, D.J. (1999). The developing mind: toward a neurobiology of interpersonal experience. New York: The Guilford Press.

Siegel, D. J., & Hartzell, M. (2003). Parenting from the inside out: how a deeper self-understanding can help you raise children who thrive. New York: J.P. Tarcher/Putnam.

Spear, L.P. 2000. The adolescent brain and age-related behavioral manifestations. Neuroscience Biobevavioral Review, 24, 417-463.

Straussner, S. L., & Phillips, N. K. (2004). Understanding mass violence: a social work perspective. Boston: Pearson A and B.

Waters, E., Merrick, S., Treboux, D., Crowell, J., Albersheim, L. (2000). Attachment security in infancy and early adulthood: a twenty-year longitudinal study. Child Development, 71(3), 684-689.

Wise, R. A. (1996). Neurobiology of addiction. Current Opinion in Neurobiology, 6(2), 243-251.

Yurgelun-Todd, D., Killgore, W.D., Young, A.D. (2002). Sex differences in cerebral tissue volume and cognitive performance during adolescence. Psychological Reports, 91: 743-757.

No comments:

Post a Comment