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Attachment and Substance Abuse: Changing the Substance Abuse Treatment Paradigm

“They don’t care what you know till they know that you care”

Paradigm Shift placard with night lights on backgroundTreating addiction is a complicated process requiring an in-depth journey from childhood to the present. Individuals suffering from addiction have long-standing issues prior to abusing drugs or other addictive behavior. Additionally, absent a glimpse into why an addict eventually turned to substances or addictive behavior to avoid emotional pain, the likelihood of wellness is substantially impeded. It is imperative to uncover what destructive patterns exist today as a direct result of past trauma and abuse; thus, the need to avoid emotional pain through addictive substances and behavior.  

Abigail’s story

Abigail, a 47-year-old Caucasian teacher had been married to Bill, 60, for 8 years. Both of them were sober and had been previously married without children.

Abigail sought treatment at an outpatient clinic for an addiction to Xanax. She had previously been sober for 10 ½ months, went to Alcoholics Anonymous meetings daily, had an AA sponsor, read the Big Book, worked through the steps of AA with her sponsor, did service work and prayed. By most definitions of Addiction Treatment, she should have remained sober. Both Abigail and Bill were long-time members of AA, well respected in the community and from the outside their life seemed “perfect”.  

Therapeutic Insight

Immediately the clarity that merely the cessation of drugs and alcohol has not been enough is clear. Additionally, it becomes clear that the prototypical treatment paradigm of don’t drink, go to meetings, get a sponsor, work steps and help others may not be enough.

Abigail reported that she had three older sisters and her mother and father had been married for 60 years prior to her father’s death three years ago. She expressed, “I was my dad’s favorite, we would go places together, play together and I idolized him.” What is more, her dad was a well-respected and wealthy surgeon and her mother came from a very wealthy family. Although to the outside world all appeared posh, dad was an abusive alcoholic who drank at home and blacked out daily. He would fall asleep in the living room watching porn and Abigail was responsible for turning off the porn and helping her dad to bed, beginning at age 7 or 8. Additionally, he was physically abusive to Abigail’s mother in the presence of the children. Nevertheless, the family would wake up the next day and mom was “cheery” and “acted as if the night before never existed.”  

When Abigail presented for treatment for Xanax addiction, it quickly became apparent that there was a direct link between her early childhood and her drug usage before and after sobriety. Furthermore, it was evident her cycle in relationships throughout her life became a replica of her childhood dynamics in her mother and father’s marriage.

“I grew up where dad was the King of the castle and it was critical to make sure he was protected and maintained respectability,” she said, adding, “I thought it was normal to fantasize, lie to the point of believing the lie (“I had to do this to protect the family”) and protect the white picket fence.”

Upon being asked what she did when dad was abusive to mom, she stated, “I spent a lot of time in my closet playing with dolls, this was my safe place.”

Therapeutic Insight

Abigail’s childhood experiences began to shape who she would become as an adult. The external working model for her life was one of distrust (dad’s abusive behavior), dishonesty (protect the external integrity of Dad and his position in society) and lack of safety (hiding in the closet). As John Bowlby, one of the pioneers of Attachment Theory, posited, Abigail’s childhood experiences and relationships created the “Internal working model” for how she perceived herself and others relationally as an adult.

Abigail admitted that as she reached her teens, although the relationship between her father and herself remained “incredible” she began to use several substances to “relieve stress.” It was pointed out that her closet and drugs became her “safe haven.” Thus, regardless of whether it was isolation, fantasy, or drugs, she utilized addictiveness to avoid pain. Likewise, she reported that her relationship with Bill was extremely controlling and both physically and emotionally abusive; yet, she stated, “He is a great man who loves me.”

Therapeutic Insight

George Vaillant stated, “Most psychopathology seen in the alcoholic (drug addict, sex addict etc.) is the result not the cause of alcohol abuse.” Hence, it is reasonable to suggest that the origin of Abigail’s addiction began well before she commenced drug abuse and quite possibly as a means of avoiding emotional pain derived from unhealthy childhood attachment patterns. More importantly, the normative patterns of lacking authenticity and vulnerability, codependency and seeking a safe haven in addictive behavior and substances, mimics her childhood attachment modeled in childhood.

During the initial sessions of individual therapy, Abigail had a difficult time building trust with her therapist as evidenced by reluctance to discuss childhood and current marital dysfunction. She also expressed concern whether she would be discharged if she relapsed or didn’t make changes “quick.” Initial treatment, both individual and group, was devoted to identifying some of Abigail’s challenges as related to attachment insecurity. Additionally, it was important to reassure Abigail that therapy would be an ongoing process and that group and individual therapy was a safe place to examine insecure attachments.

As treatment continued, the therapeutic relationship became one of trust and security in sharing honestly and allowing for loving confrontation. Through self-disclosure by Abigail’s therapist, maintaining consistent and loving boundaries and regularly conveying that she is loved and accepted, Abigail began to identify treatment as a “safe base” and observe secure attachment modeled for her. This was evidenced by statements she made such as, “I finally feel safe enough to let you know how much pain I am in,” and, “I have never been part of a community like this where people really care about you when you share shameful things about yourself.”  

Therapeutic Insight

Therapists must be able to challenge, soothe, care, love, and, if necessary, fight with the patient if they are able to provide a full range of emotional experience that can potentially come alive in an authentic relationship… The inability to establish healthy relationships is a major contributing factor to relapses and the return of substance use.” (Flores, 2004, p. 259).

Following Abigail’s recognition that she was safe and loved, she began to identify how her adult relationships replicate her childhood relationships and modeling. She also commenced to realize that her security in others was delusional and she needed to begin building a relationship with self. During the course of her life and participation in therapy, therapists consistently told Abigail that she had to love herself before she could love another and her response was “how?” The method that Abigail stated was “the game changer”, was practicing inner child work as a means of building a relationship with self.  Abigail began to communicate and foster a healthy relationship between scared “little Abigail” and “adult Abigail”. She learned that most of her life, adult Abigail had abandoned the little girl inside herself as she had been abandoned as a child.  

Moreover, she was able to acknowledge how her “addictiveness”, whether it be relationships, food, sex etc. are inextricably linked to how she learned to respond to unsafe and insecure attachment relationships as a child. She realized that as a child her internal working model created the ongoing belief that 1) attachment figures are not trustworthy; and 2) attachment figures are dishonest and inconsistent.  Thus, she began to utilize addictive behavior, including drugs and alcohol, to temporarily regulate affect and avoid severe emotional pain.

Concluding thoughts about treating addiction through Attachment:

The above example exemplifies a brief description of the importance of addressing family of origin issues in conjunction with Attachment Theory.  By identifying patterns learned and modeled during childhood (Internal Working Model) as a means of connecting adult patterns, the patient is able to gain a better understanding of why they do what they do.  Likewise, it provides an opportunity for the patient to begin processing the pain, sadness and anger typically felt when uncovering the link between childhood modeling and adult behavior.  

The patient’s identification of insecure attachments and modeling and the adult behavior therefrom, offers a well-defined awareness of why the patient has utilized maladaptive behavior and substances to regulate emotion and avoid pain.  As a result of this journey, the patient has an improved ability to actively participate in securely attached models illustrated during treatment and therapy, hence the ability to progress towards corrective experiences and develop a level of self-love.

Overall, Flores correctly expressed “When the patient learns to self-soothe and regulate their emotions they will stop looking to outside sources such as drugs, sex or relationships to achieve this goal (Flores, 2004).

Attachment and Substance Abuse: Changing the Substance Abuse Treatment Paradigm


David M. Kolker, LCSW, J.D., MCAP

David Kolker is a Licensed Clinical Social Worker who has a law degree from SIU Carbondale and a Master’s in Social Work from Florida Atlantic University. He is the Clinical Director and CEO of SLO Recovery Centers in Delray Beach, Florida. He can be reached at [email protected] or by visiting the website at https://slorecoverycenters.com.

APA Reference
Kolker, D. (2018). Attachment and Substance Abuse: Changing the Substance Abuse Treatment Paradigm. Psych Central. Retrieved on July 22, 2019, from https://psychcentral.com/lib/attachment-and-substance-abuse-changing-the-substance-abuse-treatment-paradigm/
Scientifically Reviewed
Last updated: 8 Oct 2018
Last reviewed: By a member of our scientific advisory board on 8 Oct 2018
Published on Psych Central.com. All rights reserved.