heroin as an attachment substitute? differences in attachment representations between opioid,...

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Heroin as an attachment substitute?Differences in attachmentrepresentations between opioid,ecstasy and cannabis abusersAndreas Schindler a , Rainer Thomasius a , Kay Petersen a & Peter-Michael Sack aa Clinic of Psychiatry and Psychotherapy, University MedicalCenter Hamburg-Eppendorf , GermanyPublished online: 19 May 2009.

To cite this article: Andreas Schindler , Rainer Thomasius , Kay Petersen & Peter-Michael Sack(2009) Heroin as an attachment substitute? Differences in attachment representations betweenopioid, ecstasy and cannabis abusers, Attachment & Human Development, 11:3, 307-330, DOI:10.1080/14616730902815009

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Heroin as an attachment substitute? Differences in attachment

representations between opioid, ecstasy and cannabis abusers

Andreas Schindler*, Rainer Thomasius, Kay Petersen and Peter-Michael Sack

Clinic of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf,Germany

(Received 7 June 2008; final version received 12 February 2009)

Earlier studies indicated a relation between fearful-avoidant attachment andsubstance abuse. This study compares attachment representations (FamilyAttachment Interview; Bartholomew & Horowitz, 1991) of three groups ofsubstance abusers and non-clinical controls. Heroin abusers (N ¼ 22) weremainly fearful-avoidant, ecstasy abusers (N ¼ 31) were preoccupied, fearful-avoidant and dismissing-avoidant, cannabis abusers (N ¼ 19) were mainlydismissing and secure, and controls (N ¼ 22) were mainly secure. Groups diddiffer in their level of psychosocial functioning (GAF) (cannabis 4 ecstasy 4opioids). Differences in attachment prevailed when GAF was controlled. Basedon the self-medication hypothesis we understand the preferences for specificsubstances to be influenced by specific attachment strategies. Heroin seems to beused as an emotional substitute for lacking coping strategies. Cannabis seems tobe used to support existing deactivating and distancing strategies. Ecstasy abusewas related to insecure attachment but not to a specific attachment strategy.

Keywords: attachment; substance abuse; addiction; opioids; heroin; ecstasy;cannabis

Introduction

In recent decades attachment research has gathered overwhelming evidence for aconnection between insecure attachment and psychopathology. A recent overview byMikulincer and Shaver (2007) lists more than 200 studies and gives a detailedaccount of relations between different forms of insecure attachment and differentaspects of psychopathology. Substance use disorders (SUDs), too, are related toinsecure attachment. But due to the complexity of SUDs, there remain a number ofopen questions, e.g. concerning the role of trauma and comorbid disorders,concerning possible interactions in the course of the disorder, and concerningmethodological issues. The current study addresses the question of whether SUDsare generally linked to the same pattern of attachment or if there are differencesamong consumers of different substances. Below, we first briefly describe a generalmodel of the link between SUDs and insecure attachment, then consider differencesamong the insecure attachment groups, and then analyze the emotional effects ofdifferent substances and their possible links with attachment insecurity.

*Corresponding author. Email: [email protected]

Attachment & Human Development

Vol. 11, No. 3, May 2009, 307–330

ISSN 1461-6734 print/ISSN 1469-2988 online

� 2009 Taylor & Francis

DOI: 10.1080/14616730902815009

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Insecurity, emotional distress and self-medication

Secure (autonomous) attachment is associated with flexible and functioning ways ofcoping. As such, and given the low or absent frequency of secure attachment amongSUDs, it would seem that attachment security offers some insulation against SUDs1.Several studies report a link between SUDs in general and insecure attachment(Mikulincer & Shaver, 2007; Schindler, Thomasius, Sack, Gemeinhardt, Kustner, &Eckert, 2005). Insecure attachment is associated with emotional distress and withdeficits in coping. It is a risk factor for a variety of mental health problems includingSUDs (Egle, Hardt, Nickel, Kappis, & Hoffmann, 2002). Psychoactive substancesstimulate brain reward systems, and produce a reliable, short-term change ofaffective and physiological states. Within a multi-factorial model substance abusehas been found to be a ‘‘self-medication against emotional distress’’ (Newcomb,1995, p. 14), an attempt to cope with ‘‘emotional instability and lack of control’’(Petraitis, Flay, Miller, Torpy, & Greiner, 1998) and with an overall pattern ofaffective, cognitive and behavioral dysregulation (Dawes et al., 2000; Sullivan &Farrell, 2002). Within a multi-factorial model of SUDs (Khantzian, 1997), the self-medication hypothesis explains why insecure individuals run a higher risk to gobeyond the stage of experimental or occasional substance use and to develop a SUD.

SUDs in general and specific patterns of attachment

A number of studies have explored the relation between SUDs in general and specificpatterns of insecure attachment. Studies using the Adult Attachment Interview(AAI; Main, Goldwyn, & Hesse, 2003) produced inconsistent results with mainlydismissing (Allen, Hauser, & Borman-Spurell, 1996), dismissing and preoccupied(Rosenstein & Horowitz, 1996), preoccupied and unresolved (Fonagy et al., 1996),and unresolved2 attachment representations (Riggs & Jacobvitz, 2002). Studiesworking with the Hazan and Shaver Self-Report (Hazan & Shaver, 1987) mainlyindicate a link with avoidant attachment styles (Finzi-Dottan, Cohen, Iwaniec,Sapir, & Weizman, 2003; Mickelson, Kessler, & Shaver, 1997). In an earlier studybased on the Family Attachment Interview (Bartholomew & Horowitz, 1991),Schindler et al. (2005) found mainly fearful-avoidant attachment representations.The avoidant attachment style in the Hazan and Shaver (1987) Self-Report and thefearful-avoidant attachment style in the Bartholomew (1990) self-report measuresare defined almost identically. Both can serve as ‘‘surface indicators’’ for the fearful-avoidant attachment representation as assessed in the Bartholomew interview(Bartholomew & Horowitz, 1991; Shaver & Mikulincer, 2002). Summing up theevidence specificity of attachment insecurities and SUDs, there are inconsistentresults from AAI-studies and some evidence for a link between SUDs in general andfearful-avoidant attachment from HSSR and Bartholomew studies3.

There is little empirical support for a link between preoccupied attachment andSUDs. Preoccupation is associated with strategies of hyper activation of theattachment system (Kobak, Cole, Ferenz-Gillies, Fleming, & Gamble, 1993) and ofcloseness seeking in attachment relationships (Hazan & Shaver, 1987; Main, 1991).These strategies do not seem to be associated with SUDs in general, but might play arole in the abuse of stimulants.

There is some inconsistent empirical evidence for a link between dismissingattachment and SUDs in two AAI-studies (Allen et al., 1996; Rosenstein &

308 A. Schindler et al.

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Horowitz, 1996). Additionally there might be an unknown number of ‘‘dismissing’’individuals in the avoidant category of the HSSR. There is no evidence for a linkbetween dismissing attachment and SUDs from studies using the Bartholomewmodel. Dismissing individuals cope with attachment-related distress by deactivatingtheir attachment system (Kobak et al., 1993), they actively dismiss attachment needs,experiences and relationships (Hesse, 1999; Main, 1991). Dismissing attachment canbe described as a deactivating and distancing strategy. The interpersonal behavior isconsistent with findings of withdrawal, social alienation and ‘‘low bonding tofamily’’ in substance abusers (Hawkins, Catalano, & Miller, 1992). Dismissingattachment strategies and substance abuse (in the sense of self-medication) aim at asimilar goal, the deactivation of painful affective states. However, dismissingindividuals are usually able to deactivate their attachment system without the use ofpsychoactive substances. They might use them to support or enhance theirattachment strategy. The more they are able to effectively regulate their negativeaffective states, the less they will need psychoactive substances for this purpose.

Empirically, the best-established link is the one between SUDs and fearful-avoidant attachment. The concept of fearful-avoidance was developed byBartholomew (1990). Shaver and Mikulincer (2002, p. 154) point out the differencesbetween dismissing and fearful avoidance: ‘‘Whereas dismissing avoidance involvesthe adequate functioning of deactivating strategies and inhibition of acknowledgingthreat-related cues and attachment needs, fearful avoidance may involve the collapseof these strategies under severely stressful conditions. Fearfully avoidant individualssimultaneously want closeness to attachment figures but also feel unable to trust andrely on them. This may cause their attachment systems to remain activated whiletheir behavioral strategies suggest deactivation.’’ Fearful individuals seem toperceive attachment-related distress in the way preoccupied individuals do; unlikethem they do not view the seeking of closeness as a viable option (Shaver &Mikulincer, 2002), and they do not adopt a hyper-activating strategy. Also, unlikestraight forward avoidant or dismissing individuals, they do not possess thedefensive mechanisms of a deactivating strategy. They do not seem to have anyattachment strategy of coping with attachment-related emotional distress. Once theseindividuals have realized that they are able to ‘‘medicate’’ their distress, substanceabuse can become an attractive option in spite of its negative consequences. From anattachment point of view, individuals with fearful-avoidant representations run thehighest risk to rely on psychoactive substances in order to cope with emotionaldistress.

Specific SUDs and specific patterns of attachment

Psychoactive substances share several common effects. They all stimulate brainreward systems, they all have an impact on affective states and on the level ofphysiological activation, and they all are potentially addictive. Beyond this are manyspecific effects of each substance. Given the wide variety of psychoactive substancesavailable today, the consumer is faced with a ‘‘choice’’ of substances. The abuse ofdifferent substances might be an attempt to cope with specific forms of emotionaldistress (Frosch & Milkman, 1977). From an attachment perspective the mostrelevant dimensions are emotional activation vs. deactivation and closeness seekingvs. distancing. Along these dimensions, psychoactive substances can roughly bedifferentiated as sedatives or stimulants.

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Sedating substances (e.g. alcohol, opioids, cannabis, benzodiazepines, etc.) resultin physiological and emotional deactivation, in an inhibition of cognitive processes,and in withdrawal and distancing from others. These deactivating and distancingeffects might be preferred by individuals with dismissing-avoidant and fearful-avoidant attachment strategies. Stimulants (e.g. cocaine, amphetamine, ecstasy, etc.)activate physiological, affective and cognitive processes. At the same time they leadto distortions in perception and reality testing (Julien, 2000). Though userssubjectively perceive a facilitation of social contact, prolonged stimulant abusedisrupts relationships and leads to social alienation (Hawkins et al., 1992; Newcomb,1995). Stimulants might be attractive to preoccupied individuals with hyper-activating and closeness seeking strategies. There are no studies yet considering thispossibility.

No study so far compared abusers of different substances. Only a few of theexisting studies were designed to examine SUDs, and only some of these do mentionwhich substances were consumed. The only studies of this kind refer to alcohol(Brennan & Shaver, 1995; Magai, 1999; McNally, Palfai, Levine, & Moore, 2003;Senchak & Leonard, 1992) and heroin (Finzi-Dottan et al., 2003; Schindler et al.,2005). The alcohol studies were conducted in non-clinical samples and producedinconsistent results. The heroin studies were clinical and used different measures andsamples. Finzi-Dottan et al. (2003) studied a sample of long-term heroin addicts in adetoxification unit using the HSSR (Hazan & Shaver, 1987). Schindler et al. (2005)studied attachment representations in a sample of adolescent opioid abusers in anoutpatient family therapy program using the Family Attachment Interview(Bartholomew & Horowitz, 1991). In spite of different measures and samples,both studies indicate a relation between opioid abuse and fearful-avoidantattachment.

The special case of opioids

Additionally to these findings opioids are emotionally and neuro-chemically relatedto attachment. Their consumption results in affective states, which are similar to thesafe haven function. And attachment-based animal studies indicate a crucial role ofendorphins (endogenous opioids) in the neuro-chemical transmission of attachmentbehaviors4. Exogenous as well as endogenous opioids stimulate a set of specificreceptors (m, k-, and d-receptors) that are not stimulated by other availableexogenous substances. Highest concentrations of opioid receptors are found in thelimbic system and related brain areas. A considerable number of animal studiesaddressed the role of the endogenous opioid system in the neuro-biologicalfoundations of attachment. Separation distress has been studied repeatedly. Distressvocalizations of young rats after separation from their mothers decreased whenopioids were administered and increased when opioid antagonists were given(Panksepp, 1998). Several studies in primates showed that blocking opioid receptorswith antagonists increased the need for care. Young animals expressed this need byseeking closeness to mothers. Adult animals turned to their peers to be groomed(Martel, Nevison, Simpson, & Keverne, 1995). Mother animals, too, displayed thismotivation to be groomed. Nonetheless, opioid antagonists did not change mothers’care giving behavior towards their offspring (Graves, Wallen, & Maestripieri, 2002).However, opioids decreased the motivation to be groomed (Keverne, Martensz, &Tuite, 1989). D’Amato (1998) reported that, in mice, the analgesic effect of morphine


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was increased by the closeness of fellow animals. But these had to be kin; strangemice did not produce this effect. These results indicate that the same neural circuitsregulate the satisfaction derived from social attachments and the effects of opioidconsumption (Panksepp, 1998; Panksepp, Knutson, & Burgdorf, 2002). Lack ofopioid agonists (e.g. because of blocked receptors) increases care seeking. Opioidconsumption decreases the need for social interaction. Attachment related distresscan be relieved by opioid consumption. This raises the question whether, in humans,the attractiveness of opioids depends on the quality attachment representations.

In humans, the consumption of opioids results in a syndrome of analgesia,respiratory suppression, cough relief and pupillary response. Emotionally it causes amixture of euphoria and sedation described as ‘‘contentedness, well-being and feelingcarefree’’ and as ‘‘a feeling of calm, a relief from fear and sorrow’’ (Julien, 2000,p. 260). This emotional state is very close to that of a child finding security andcomfort in its mother’s ‘‘safe haven’’ (Bowlby, 1969/1982; Cassidy, 1999). Zeifmannand Hazan (1997) suppose that attachment includes the conditioning of theendogenous opioid system to the stimulus of another individual (the attachmentfigure). The conditioning is based on the repeated experience of calming down andendorphin release in interactions with this individual. This process can be more orless successful. The experience of being cared for, of being comforted and of findingsecurity in the safe haven of the attachment figure forms the basis of secure-autonomous attachment representations. It is associated with the activation of theopioid system and results in the successful conditioning of the opioid system to thestimulus of the attachment figure. Later on, this allows the activation of the opioidsystem in reaction to the conditioned stimulus of social interaction. The morenegative early experiences are, the less secure the attachment representation and theless complete the conditioning. This, in turn, makes it more difficult to activatethe opioid system by social interactions; the consumption of opioids is becomingmore attractive. Thus, negative attachment experiences, insecure attachmentrepresentations and unsuccessful conditioning constitute a specific risk factor foropioid abuse. Several authors speculated that opioid abuse in humans might be anattempt to substitute lacking attachment strategies (Insel, 2003; MacLean, 1990;Zimmer-Hofler & Kooyman, 1996).

Empirical findings of fearful-avoidant attachment in opioid abusers support thismodel, but we lack controlled comparisons to abusers of other substances. We donot know yet if fearful avoidance is specific for heroin abusers or for substanceabusers in general. A link to SUDs in general would strengthen the hypothesis thatpsychoactive substances are consumed regardless of the specific emotional effects ofdifferent substances. Common factors would be more important than substancerelated effects. Differences between abusers of different substances would support thehypothesis that substances are chosen due their specific emotional and social effects.We looked for abusers of another sedating substance without a link to the neuro-biological transmission of attachment, and for a contrasting stimulant. Allsubstances should be illicit. Severity of abuse as well as age and social context ofabusers should be similar. These criteria were met by abusers of cannabis andecstasy.

The psychological and social effects of cannabis abuse are complex and in partcontradictory. Cannabis (d9-THC) influences different brain circuits at differentlevels. The effects are transmitted by a special class of receptors and by theendogenous agonist anandamid (Julien, 2000). There are no relations to the opioid


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system or to the neural transmission of social interactions. Cannabis has mainlydeactivating, relaxing and sedating effects, especially in higher doses. Its affectiveconsequences can be diverse. Reports range from euphoria, a heightened sense ofwell-being and a relief of anxiety to dysphoria and increased anxiety. Cannabisrestrains cognitive functioning in a number of ways. As a consequence, reality testingand social interactions are impaired. Though cannabis is often consumed in groups itresults in trance-like withdrawal and a distancing from social relationships (Perez-Reyes, 1999; Petersen & Thomasius, 2007).

With this pattern of psychological effects cannabis, too, might serve as a chemicalsubstitute for a deactivating and distancing attachment strategy. According to themodel above, this would imply mainly fearful-avoidant and dismissing-avoidantpatterns of attachment. However, cannabis lacks the close biochemical relation withthe attachment system. So the relation between cannabis abuse and these patterns ofattachment might be less pronounced than in opioid abusers.

The effects of ecstasy (MDMA) differ considerably from those of opioids andcannabis. Ecstasy increases the release and inhibits the reuptake of serotonin (5-HT).This leads to an affective and vegetative activation, stimulation and euphoria.Additionally it has a so-called ‘‘entactogenous’’ effect (Nichols, 1986). That meansusers get an intensive sense of closeness to others. The feeling of being together doesnot necessarily mean a real contact or a close relationship in the sense of attachmenttheory. There are no hints of a relation between ecstasy effects and biochemicalcorrelates of attachment. Ecstasy is mainly used in party contexts. A centralmotivation of ecstasy use is the wish to get in touch with others more easily (Cottler,Womack, Compton, & Ben-Abdallah, 2001; Solowji, Hall, & Lee, 1992; Tossmann,Boldt, & Tensil, 2001). This leads to the hypothesis that ecstasy might be especiallyattractive to socially inhibited and fearful individuals (Boys, Marsden, & Strang,2001; Treder, 2004). In contrast to our ideas on opioid and cannabis abusers, theseindividuals would not adopt a strategy of avoidance and deactivation but one ofcloseness seeking and activation. These strategies are usually associated withpreoccupied attachment. Therefore, we would expect ecstasy abusers to be morepreoccupied than cannabis and opioid abusers.

Research questions

Do abusers of different substances differ in attachment representations?

Do heroin abusers differ from abusers of other sedating substances?

Does the abuse of sedating substances go along with dismissing-avoidant and/or fearful-avoidant attachment?

Does the abuse of stimulants go along with preoccupied attachment?

Hypotheses

(1) Individuals with opioid use disorders have lower levels of secure attachmentthan non-SUD controls and individuals with cannabis and ecstasy usedisorders. Individuals with opioid use disorders have higher levels of fearful-avoidant attachment than non-SUD controls and ecstasy abusers.


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(2) Individuals with cannabis use disorders have higher levels of fearful-avoidantand dismissing-avoidant attachment than individuals with ecstasy usedisorders and non-SUD controls.

(3) Individuals with ecstasy use disorders have higher levels of preoccupiedattachment and lower levels of fearful-avoidant and dismissing-avoidantattachment than individuals with opioid and cannabis use disorders.

(4) Non-substance abusing controls have higher levels of secure attachment thanindividuals with opioid, ecstasy or cannabis use disorders.

Method

Participants

Data were collected in the government funded research project ‘‘EcstasyAbuse–health and psycho-social consequences’’ conducted at the University MedicalCenter Hamburg-Eppendorf, Germany (Thomasius, 2000; Thomasius, Petersen,Zapletalova, Wartberg, Zeichner, & Schmoldt, 2005; Thomasius et al., 2006).Informed consent was given by all participants. They received a small com-pensation for their participation in 3 days of medical and psychological testing.They received feedback about their physical and cognitive status, which seemed to beespecially attractive to ecstasy abusers, worrying about the consequences of theirconsumption. The project focused on the ‘‘techno-scene,’’ which is best described as asubculture with a preference for ‘‘techno-music’’ and ‘‘techno’’ nightclubs, and astrong habit of ecstasy abuse. In a study in Hamburg, Germany, 75% of ecstasyabusers defined themselves as part of this scene (Rakete & Fluesmeier, 1997).‘‘Techno’’ is a kind of electronic dance music with fast, heavy and monotonous beats,creating trance like states in dancers. These effects are often enhanced by theconsumption of drugs. Ecstasy is the most important substance, whileother amphetamines (speed), cocaine, cannabis, alcohol, LSD, etc. are used as well.N ¼ 155 participants were actively recruited in techno nightclubs. Since we lookedfor different groups of substance abusers as well as non-drug users, there was no pre-selection. However, some persons refused to take part, and we did not approachpersons who were obviously severely intoxicated. For this study we selected N ¼ 31ecstasy abusers and N ¼ 19 cannabis abusers as described below. While ecstasyabuse is common in these clubs, the cannabis group was special. Cannabis abuserswere part of the techno-scene but abstinent of ecstasy. Recruitment did not yield asufficiently numerous group of non-drug users, and it did not yield anyopioid abusers. We did find individuals who claimed to be drug-free and who weremotivated to participate. However, urinalyses showed that most of them hadbeen using drugs. Thus, we selected a control group of non-drug using siblings ofheroin dependent adolescents from an earlier study (Schindler et al., 2005;Thomasius, 2004; Thomasius, Sack, et al., 2005). Since we did not find any opioidabusers in nightclubs, and it was impossible to recruit them from the ‘‘heroin-scene,’’we relied on a clinical sample from the outpatient drug treatment unit at theUniversity Medical Center. Each consecutive opioid abuser coming in for treatmentwas screened and included if inclusion criteria were met. Once they had decided totake part in treatment, it appeared, agreement to participate in research followedeasily. However, two persons with severe legal problems and one person withparanoid symptoms refused to take part. Opioid abusers were assessed at


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the beginning of treatment, thus receiving a much more thorough assessment thanusual.

Several measures required fluency in the German language. Thus, all participantswere Germans from a metropolitan area, leaving the important group of immigrantsunconsidered. The age span of our study included pupils, students, trainees andworking persons. To gain a comparable measure, we assessed the proportion ofindividuals who had interrupted school or work as a consequence of substanceabuse. Typically they either were intoxicated at school/work or they missed itrepeatedly and eventually were fired. Groups did not differ significantly in genderdistribution, with about one third of women and two thirds of men. Table 1 providesan overview of sample characteristics and comparisons between groups.

Group 1: Opioid abusers

The opioid group were N ¼ 22 individuals with a primary diagnosis of opioiddependence (DSM-IV 304.00) or opioid abuse within a pattern of polysubstancedependence (DSM-IV 305.50 and 304.80). Heroin was the main drug of all opioidabusers, though all of them additionally consumed other substances like alcohol,cannabis, tranquillizers and cocaine. For between-group comparisons we neededgroups with a comparable level of severity of drug use. This is difficult to establishacross substances. Heroin users usually have a more rapid development of addictionthan users of other substances. We therefore recruited a group of opioid abusers witha shorter period of substance abuse and consequently a younger age. Studies on ageand attachment do not report significant differences between 18-year-olds and olderadults (van IJzendoorn & Bakermans-Kranenburg, 1996), so we do not expect thisage difference to influence attachment data. Opioid abusers had the highestproportion of individuals who had interrupted school or work (45%, n ¼ 10) as aconsequence of substance abuse. Opioid abusers were assessed at the beginning of anoutpatient treatment.

Group 2: Ecstasy abusers

We included N ¼ 31 individuals with a primary diagnosis of ecstasy dependence orecstasy abuse (DSM-IV 304.40 or 305.70). Individuals with additional substancerelated diagnoses were excluded. Ecstasy (MDMA) had to be the main drug. Wetolerated the typical pattern of polysubstance use often including other stimulants,alcohol, cannabis and hallucinogens. Two individuals (6.5%) had been fired fromvocational training. They had repeatedly been unable to work after weekends ofexcessive drug abuse.

Group 3: Cannabis abusers

This group were N ¼ 19 individuals with a primary diagnosis of cannabisdependence or cannabis abuse (DSM-IV 304.30 or 305.20). Cannabis had to bethe main drug with a prevalence of at least 10 days of consumption within thelast month. Individuals with additional substance related diagnoses wereexcluded. Occasional consumption of other substances was tolerated on less than5 days within the last month. No one from this group had interrupted schoolor work.


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Group 4: Controls

A group of N ¼ 22 non-clinical, non-drug using controls was compared to thethree SUD-groups. These were siblings of heroin dependent youth, taking part inan outpatient family therapy study (Schindler et al., 2005; Thomasius, 2004;Thomasius, Sack, et al., 2005). Thirty-nine of a total of 65 siblings participated intreatment. They were self-selected, being the ones willing and able to take part infamily therapy for the sake of their drug dependent siblings. Two siblings whosuffered from a SUD were excluded from the control group. N ¼ 22 individualswere selected to match the opioid group in age and gender. Though controls werenot siblings of the current opioid group, they came from similar families; we canassume family and socio-economic background to be similar to the opioid group.Contrary to the opioid group, no one from this group had interrupted school orwork.

Measures

All psychiatric, psychological, psychodynamic, neuropsychological, neurologicaland physical assessments were carried out within 3 days. Data presented in this paperincluding status and history of substance use, psychiatric diagnoses (DSM-IV, GAF,SCL–90) and attachment interview were collected in the morning of the first day.These measures were administered and subsequently coded by two trained clinicalpsychologists, who were aware of substance abuse but blind for attachment relatedhypotheses and research questions.

Attachment: Family Attachment Interview (Bartholomew)

Attachment representations were assessed using the German version (Doll, Mentz,& Witte, 1995) of the four-category model of attachment (Bartholomew &Horowitz, 1991). The Bartholomew model is usually associated with self-reportmeasures assessing attachment styles and focusing on interpersonal behavior inclose relationships (Bartholomew & Horowitz, 1991; Hazan & Shaver, 1987); inthis study we worked with the Family Attachment Interview (FAI) assessingrepresentations of attachment related experiences in the family of origin and withrelevant others (Bartholomew & Horowitz, 1991; Bartholomew & Moretti, 2002).Like other measures of attachment representations it puts a focus on defensivestrategies and discourse properties in reporting relational experiences with parentsin childhood5. The semi-structured FAI takes about 60 minutes. Bartholomewdeveloped a Family and a Peer Attachment Interview, and an integration of both,the History of Attachment Interview. Questions of the FAI are similar to the AAI(family background, parents’ marital relationship, self description as a child,relationships to mother and father described with adjectives and specific memories,what happened when you were upset, unhappy, physically or emotionally hurt,separations, getting lost, running away, rejections by parents, were parentsdisappointed with you, threats and discipline, ever been afraid of parents, did youfeel loved and understood, current relationship with parents, changes in relation-ship since childhood, effects of growing up the way you did, how would you haveliked your parents to be different, how do you think that your parents would haveliked you to be different). An important difference to the AAI is loss and trauma,


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which are not asked for in the Bartholomew interview. Consequently, there is no‘‘Unresolved’’ attachment category. Bartholomew’s model is based on the earliestapproaches of the AAI (Main, Kaplan, & Cassidy, 1985) and of Hazan and Shaver(1987). Bartholomew adopted secure and preoccupied categories of the earlierapproaches, but differentiated between two avoidant categories: fearful-avoidantand dismissing-avoidant. Bartholomew employed Bowlby’s (1973) theory ofinternal working models (IWMs) of the self and the caregiver. The combinationof these IWMs in a positive or negative form produces four patterns ofattachment: secure, preoccupied, fearful, and dismissing (Bartholomew, 1990,1997; Bartholomew & Horowitz, 1991). Bartholomew conceptualizes them asprototypes (Bartholomew, 1997; Griffin & Bartholomew, 1994). These can beanalyzed as categories by classifying each individual to the prototype he or sheresembles most. The model also allows a gradual assessment of an individual’ssimilarity to each prototype. The degree to which a participant resembles each ofthese prototypical descriptions is coded on five-point scales in the German version(Doll, Mentz, & Witte, 1995) as opposed to seven-point and nine-point scales inthe original version. Bartholomew and Horowitz (1991) characterize the fourprototypes as follows:

Secure: Positive model of self, positive model of other, comfortable with intimacy andautonomy, valuing of intimate friendships, capacity to maintain close relationshipswithout losing personal autonomy, coherence and thoughtfulness in discussingrelationships and related issues.

Preoccupied: Negative model of self, positive model of other, preoccupied withrelationships, over involvement in close relationships, dependence on other people’sacceptance for a sense of personal well-being, tendency to idealize other people,incoherence and exaggerated emotionality in discussing relationships.

Fearful: Negative model of self, negative model of other, fearful of intimacy, sociallyavoidant, avoidance of close relationships because of a fear of rejection, sense ofpersonal insecurity, distrust of others.

Dismissing: Positive model of self, negative model of other, dismissing of intimacy,counter dependent, downplaying of the importance of close relationships, restrictedemotionality, emphasis on independence and self-reliance, lack of clarity or credibility indiscussing relationships.

Griffin and Bartholomew (1994) report inter-rater reliabilities of the attachmentscales between a ¼ .87 and a ¼ .95. Concerning the convergent validity of themeasure, Bartholomew and Shaver (1998) report a high proportion of agreement(78%) between AAI-classifications (Hesse, 1999) and the corresponding threeattachment categories in the Bartholomew system. Fearful attachment was excludedfrom that study for the lack of a corresponding AAI-classification. Evidence for thefactorial validity of the measure was established by Brennan, Shaver, and Tobey(1991), who were able to trace back the four attachment scales to two underlyingdimensions labeled Attachment Security (secure vs. insecure/fearful) and CopingStyle (preoccupied vs. dismissing). In a principal component analysis of Germanattachment data of individuals with SUDs we were able to replicate this underlyingtwo-dimensional structure (Schindler, Thomasius, Sack, Gemeinhardt, & Kustner,2007). See van IJzendoorn and Bakermans-Kranenburg (1996) for a similar two-dimensional structure based on meta-analytic data of studies using the AAI (Main,Goldwyn, & Hesse, 2008).


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There are several German adaptations of the Bartholomew model. Doll, Mentz,and Witte (1995) translated the model into German, retranslated it into English andhad a bilingual expert check the convergence. Authors report high construct validityand overall psychometric qualities comparable to the original English version.Asendorpf, Banse, Wilpers, and Neyer (1997) report satisfying reliability and validityindices of the German version. Validity was tested in terms of correlations withrelationship measures. Grau (1999) found high internal consistencies (.86 to. 91)and 6-month retest reliabilities of. 57 to. 74. In a pre-study four clinicalpsychologists independently coded a sample of N ¼ 16 videotaped interviews withsubstance abusers. Average correlation between two coders of one interview wasRadj

2 ¼ .80.Attachment data were analyzed in four steps. First, between SUD-group

comparisons were calculated via analyses of covariance (ANCOVAs), comparingattachment scores and controlling for possible concomitants, and using theconservative Scheffe-test for post hoc comparisons (Tabachnik & Fidell, 1996).Second, groups were compared on attachment dimensions. Third, attachment scoreswere analyzed separately within each group, conducting a series of matched-pairst-tests but using a Bonferoni-adjusted a-level. Fourth, participants were categorizedaccording to the attachment prototype they resembled most. Frequencies of theseattachment categories were compared between groups using chi-squared tests andOdd’s Ratios.

Substance abuse

Substance use disorders were diagnosed according to DSM-IV criteria. Substanceuse was assessed with the structured interview of substance abuse (Thomasius,2000), asking for the use of alcohol, tobacco, illicit drugs and prescription drugs,for patterns, developments, motivations, and for illegal activities in connectionwith substance use. The interview is an adaptation of the German version of theAddiction Severity Index (Gsellhofer, Fahrner, & Platt, 1994; McLellan et al.,1992). The ASI is a standard instrument in addiction research, focusing on opioidswith their specific patterns and consequences of abuse. It had to be adapted forthe use in cannabis and ecstasy samples. Due to very different risks andconsequences of these different substances severity scores could not be reliablycompared across substances. We used GAF and SCL-90 to compare psychosocialfunctioning and severity of psychopathology (see below). Participants’ reports ontheir current substance use were validated with urinalyses, taking advantage of thebogus pipeline effect that increases veridicality of self-reports (Rose & Jamieson,1993).

Psychopathology: SCL90-R (GSI)

Severity of psychiatric symptoms was assessed with the SCL-90-R (Symptom-Checklist; Derogatis, 1986; German version; Franke, 1995). The SCL-90-R is a90-item questionnaire asking for psychiatric symptoms in the last week. SCL-90-Rincludes nine scales: somatization, obsessive-compulsive, interpersonal sensitivity,depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism. Weused the Global Severity Index (GSI) as an overall measure of number and severityof psychiatric symptoms (range: 0 to 4).


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Global Assessment of Functioning

Global Assessment of Functioning (GAF; American Psychiatric Association, 1996;Endicott, Spitzer, Fleiss, & Cohen, 1976) is a scale rating the social andpsychological level of functioning of patients. It ranges from 0 to 100, defining thelow end as ‘‘persistent danger of severely hurting self or others’’; the high end isdefined as ‘‘superior functioning in a wide range of activities.’’ Scores of 0–40 can beequated with very severe functional impairment, those of 41–70 with severe tomoderate impairment and those of 71–100 with relatively undisturbed functioning innon-clinical groups. GAF is the fifth axis of DSM-IV. The global level of functioningindicates the severity of psychiatric disorders.

Results

Table 1 shows the results of between-group comparisons of attachment scales,attachment dimensions, attachment categories and possible confounds. Groups didnot differ in gender distribution. As described above, we deliberately selected ayounger sample of opioid abusers and matched controls to this group. Thus, opioidabusers and controls were significantly younger than ecstasy abusers, with cannabisabusers ranging in between. A total of 45% of opioid abusers had been breaking offschool or job, as opposed to 6.5% in ecstasy abusers and 0% in cannabis abusers andcontrols [w2(3, N ¼ 94) ¼ 28.22; p ¼ .000***; w ¼ .55]. Controls reported signifi-cantly lower levels of psychiatric symptoms (SCL90-GSI) than opioid and ecstasyabusers, while there were no significant differences between controls and cannabisabusers or between the three SUD-groups. But SUD-groups did differ in their globallevel of functioning (GAF). Cannabis abusers scored only slightly below the non-clinical range. Opioid abusers scored lowest on the level of ‘‘severe impairment,’’ andecstasy abusers lay in between with significant differences to both other SUD-groups.

Attachment scale data show significant differences on secure and fearful-avoidantscales. Controls were more secure than all three SUD-groups. Cannabis abusers weremore secure and less fearful than the two other SUD-groups. Opioid abusers weremore fearful than all other groups. Between-group differences on attachmentscales prevailed when level of functioning (GAF) was controlled in ananalysis of co-variance: secure: F(2,94) ¼ 12.27; p ¼ .000***; etapart

2 ¼ .27; fearful:F(2,94) ¼ 20.56; p ¼ .000***; etapart

2 ¼ .38; no differences on other scales.In the two-dimensional version of attachment scales controls and cannabis

abusers were significantly more secure than opioid and ecstasy abusers. There wereno significant differences on the coping style dimension. Figure 1 visualizes theposition of the four groups on attachment dimensions.

Within-group differences between attachment scales were tested with a set ofmatched-pairs t-tests. In opioid abusers, fearful avoidance scored highest,preoccupation second and security as well as dismissiveness lowest. In ecstasyabusers, the secure scale scored lower than all three insecure scales. These did notdiffer from each other. In cannabis abusers, there were no significant differencesbetween any attachment scales. In controls, secure attachment scored higher than allother scales.

Additionally, participants were categorized according to the attachmentprototype they resembled most. Between-group comparisons of frequencies ofattachment categories were calculated by chi2-tests. The overall comparison across all


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Table

1.

Sample

descriptionsandcomparisonsofattachmentscales,dim

ensionsandcategories

ofopioid,ecstasy,andcannabisabusers

andcontrols.

Variable

Group1:

Opioid

abusers

Group2:

Ecstasy

abusers

Group3:

Cannabis

abusers

Group4:

Controls

Significant

comparisons

(Scheff

e)(N¼

22)

M(SD)

(N¼

31)

M(SD)

(N¼

19)

M(SD)

(N¼

22)

M(SD)

p

Age

19.59(3.05)

23.16(3.80)

21.30(3.08)

19.50(5.02)

15

2.001**

45

2.007*

Proportionofwomen

27.3%

35.5%

34.8%

36.4%

–n.s.

Interruptionofstudy/career

45.5%

6.5%

0%

0%

GAF1(R

ange:

0to

100)

44.95(6.00)

59.68(13.32)

69.09(16.22)

–15

2.001**

15

3.000***

25

3.019*

SCL

902(R

ange:

0to

4)

.99(.54)

1.11(.80)

.69(.47)

.43(.40)

14

4.000***

24

4.001**

AttachmentScales:

Secure

(Range:

1to

5)

1.91(.68)

1.42(.62)

2.63(1.12)

3.91(.81)

15

3.019*

25

3.000***

44

1.000***

44

2.000***

44

3.000***

Preoccupied(R

ange:

1to

5)

3.09(.92)

2.68(1.08)

2.37(1.42)

2.55(.91)

–n.s.

Fearful-avoidant(R

ange:

1to

5)

4.09(.68)

2.68(1.14)

1.79(.98)

2.27(.77)

14

2.000***

14

3.000***

14

4.000***

24

3.010*

Dismissing-avoidant(R

ange:

1to

5)

1.91(.81)

2.48(1.24)

2.58(1.26)

1.86(.89)

–n.s.

(continued)


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Table

1.

(Continued

).

Variable

Group1:

Opioid

abusers

Group2:

Ecstasy

abusers

Group3:

Cannabis

abusers

Group4:

Controls

Significant

comparisons

(Scheff

e)(N¼

22)

M(SD)

(N¼

31)

M(SD)

(N¼

19)

M(SD)

(N¼

22)

M(SD)

p

AttachmentDim

ensions:

AttachmentSecurity

3(R

ange:

74toþ4)

72.18(1.10)

71.26(1.44)

.84(1.71)

1.64(1.33)

15

3.000***

15

4.000***

25

3.000***

25

4.000***

CopingStyle4(R

ange:

74toþ

4)

1.18(1.40)

.19(2.02)

7.21(2.25)

.68(1.46)

–n.s.

Attachmentcategories:

n(%

)n(%

)n(%

)n(%

)Secure

0(0%)

1(3.2%)

7(36.8%)

15(68.2%)

Preoccupied

5(22.7%)

10(32.3%)

4(21.1%)

3(13.6%)

Fearful-avoidant

17(77.3%)

10(32.3%)

0(0%)

2(9.1%)

Dismissing-avoidant

0(0%)

10(32.3%)

8(42.1%)

2(9.1%)

Note:M¼

Mean;SD¼

Standard

Deviation;Bonferoni-adjusted;*p5

.05;**p5

.01;***p5

.001;n.s.¼

notsignificant.

1:GlobalAssessm

entofFunctioning:Higher

scoresindicatingbetterfunctioning.

2:Symptom

Checklist-90-R

(GlobalSeverityIndex):Higher

scoresindicatingmore

psychiatric

symptoms.

3:Positivescoresindicatingsecurity,negativescoresindicatingfearful-avoidance.

4:Positivescoresindicatingpreoccupation,negativescoresindicatingdismissingness.


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four groups yielded a significant difference [w2(9, N ¼ 94) ¼ 67.93; p ¼ .000***;w ¼ .85]. Additionally all six comparisons between two groups were significant. Wecalculated Odd’s Ratios to analyze the relative probabilities of attachmentcategories. In opioid abusers the probability of fearful attachment was 15 timeshigher compared to the two other SUD-groups, and 34 times higher compared tocontrols. Probability of preoccupied attachment was two times higher than incontrols. In cannabis abusers the probability of secure attachment was 30 timeshigher than in the two other SUD-groups, but four times lower than in controls. Incannabis abusers the probability of dismissing attachment was three times higherthan in the two other SUD-groups and seven times higher than in controls. Inecstasy abusers the probability of preoccupied attachment was two times higher thanin the two other SUD-groups and three times higher than in controls. Probability offearful and dismissing attachment was five times higher than in controls. In controlsthe probability of secure attachment was 15 times higher than in SUD-groups.

Discussion

Attachment scales

Results of attachment scale data confirm our expectations only in parts. As expected,controls had the highest level of secure attachment, while opioid abusers had thelowest level and cannabis abusers were in between. Unexpectedly, ecstasy abusers

Figure 1. Means and standard deviations of attachment dimensions of opioid, ecstasy andcannabis abusers and controls.


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had equally low levels of secure attachment as opioid abusers. As expected, opioidabusers had higher levels of fearful attachment than ecstasy abusers and controls,but contrary to expectations cannabis abusers had lower levels of fearful attachmentthan both other SUD-groups. Attachment scale data did not yield any significantdifferences between groups on preoccupied or dismissing scales.

Between-group differences in attachment security followed a similar pattern asdifferences in psychological functioning. Here, opioid abusers scored lowest, ecstasyabusers ranged in the middle and cannabis abusers had the highest scores of the threeSUD-groups. However, differences on attachment scales prevailed when level offunctioning was controlled. So differences in attachment cannot be explained bydifferences in psychological functioning.

Attachment categories

When attachment representations were assessed as categories, differences betweengroups as well as patterns of attachment within groups became clearer. We did finddifferences in preoccupied and dismissing attachment, which we did not find in theanalyses of attachment scales. More than three quarters of opioid abusers werefearful, the last quarter was preoccupied. The probability for a fearful attachmentrepresentation was much higher than in any other group. Among ecstasy abusers theprobability for preoccupied attachment representations was higher than in the othergroups. But when we looked at the ecstasy group alone, preoccupation was not morefrequent than fearful and dismissing avoidance. Contrary to expectations,preoccupation does not seem to be the characteristic attachment representation ofecstasy abusers. Contrary to the other SUD-groups, cannabis abusers were mainlyclassified dismissing or secure. Accordingly, the proportions of secure and dismissingattachment representations were much higher than in the other SUD-groups.Controls had a much higher probability for secure attachment representations thanany SUD-group.

Opioid abusers

The strongest relation between a specific SUD and a specific pattern of attachment isthe one between opioid abuse and high levels of fearful-avoidant attachment. Thisresult confirms earlier findings (Finzi-Dottan et al., 2003; Schindler et al., 2005). It isevidence for a special relation between attachment and opioids in humans. Itsupports the notion of opioid abuse as an emotional substitute for social attachments(Insel, 2003; MacLean, 1990; Zimmer-Hofler & Kooyman, 1996), and as an artificialstrategy of deactivation and distancing. Opioid abusers were the most severelydisturbed group in several ways. They had the lowest level of psychosocialfunctioning and the highest probability for interrupting school or work. However,controls matched them in socio-economic background. Thus, one must look beyondsocio-economic factors to other variables, including family relationship factors, toaccount for the SUDs and severity of psychopathology in this opioid abusing group.

Ecstasy abusers

Ecstasy abusers had a higher level of psychological functioning, a smaller proportionof participants interrupting school or work and a lower level of fearful attachment


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than opioid abusers. Though opioid abusers were the only clinical treatment group,the nightclub sample of ecstasy abusers matched them in the high level of psychiatricsymptoms and in the low level of secure attachment. This underpins the severity ofmental problems in the ecstasy group and the comparable level of symptom severity.Our study might have been especially attractive to those ecstasy abusers who wereconcerned with their mental and physical health, resulting in a more severelydisturbed sample. But cannabis abusers were recruited in the same way, and theywere much less disturbed. Though insecure attachment was predominant in theecstasy group, no specific representation was characteristic. Preoccupied, dismissingand fearful attachment were at similar levels. Contrary to expectations the abuse ofthe ‘‘entactogenous’’ stimulant ecstasy is not associated with a hyper-activating andcloseness seeking strategy in the sense of preoccupied attachment. There are twopossible explanations for this finding. First, the group might be heterogeneous,consisting of several subgroups. Though standard deviations were not bigger than inthe other groups, the analysis of this issue requires a much bigger sample. Second,with regard to ecstasy, other motivational and behavioral systems might be morerelevant than attachment. The ideas of Zeifmann and Hazan (1997) are interesting;they compare the attachment system (on brain level regulated by opioids) to otherintegrated systems of motivation and behavior. They report a close relation betweenamphetamine type substances and infatuation and sexual appetence (‘‘thrill’’). Theyexplicitly mention phenylethylamines (PEA), which have stimulating and slightlyhallucinogenous effects that are similar to those of ecstasy. So the abuse of ecstasymight be more closely related to other systems than attachment.

Cannabis abusers

In cannabis abusers, none of the differences between attachment scales weresignificant. With regard to attachment categories, the cannabis group was mainlydismissing and secure. This is some evidence for the expected deactivating anddistancing attachment strategy. Contrary to our expectations and contrary to opioidabusers, we did not find any cannabis abusers with fearful representations. Thisdifference between the cannabis and opioid groups underpins the importance ofBartholomew’s differentiation between fearful and dismissing avoidance. Dismissingavoidance involves functioning (though insecure) coping strategies, while fearfulavoidance does not. Dismissing avoidance has been found to be related to relativelyless severe drug abuse, while fearful avoidance was related to a more severe drugabuse (Schindler et al., 2005). Cannabis abuse does not seem to substitute lackingattachment strategies but it might support a strategy and a model of self that isrelatively positive already. According to Bartholomew and Horowitz (1991), secureand dismissing attachment representations imply a positive model of self. Thus theproportion of cannabis abusers with a positive model of self is a very high 79%(controls 77%; opioid 0%; ecstasy 36%). This high percentage is in sharp contrast tothe opioid group, where we found exclusively fearful and preoccupied representa-tions which both imply a negative model of self. However, cannabis abusers hadsignificantly lower levels of secure attachment than controls, and they met DSM-IVcriteria for SUDs. Taking attachment security and psychological functioning asindicators of mental health, the cannabis group is on the level of a slight clinicaldisturbance. Since cannabis abusers were recruited in the same nightclubs as ecstasyabusers, one might ask why they seem to be so much less disturbed. A possible


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explanation is that moving in the techno scene without taking ecstasy requires theability to resist peer-pressure. So the cannabis group might be a sample of moreassertive persons. Another reason might be the fact that cannabis is culturally muchmore accepted than ecstasy or even heroin. Within the techno subculture, ecstasy isthe most important drug. Someone who is only smoking cannabis might not even beconsidered a drug user. Additionally results might be biased by underreporting ofproblems. Dismissing attachment is linked to avoidance of relationships and tounderreporting of problems. We used urinalyses and an attachment interview insteadof questionnaires to minimize biases due to underreporting, but we cannot rule themout completely.

Controls

Results of non-substance using controls in our study were as expected. They hadhigher levels of secure attachment and lower levels of psychiatric symptoms than allSUD-groups.

Research implications

The answer to our first research question is yes: abusers of different substances dodiffer in attachment representations. In the current study, opioid abuse was linked tofearful avoidance, cannabis abuse was linked to secure and dismissing representa-tions and ecstasy abuse to insecure attachment in general. There is no general linkbetween attachment and SUDs. This has methodological and theoretical implica-tions. Methodologically, it explains inconsistent results from studies with unspecifiedsamples of substance abusers. Future studies on attachment and SUDs will have toconsider these differences and define their samples accordingly. Theoretically, ourresults strongly support the self-medication hypothesis of substances abuse.Psychoactive substances seem to be selected to create specific emotional effects,and this choice is related to attachment strategies.

The answer to our second research question is yes. Opioids were linked toattachment in a special way, differing from stimulating as well as from other sedatingdrugs. The strong relation between opioid abuse and fearful avoidance replicatedresults of earlier studies (Finzi-Dottan et al., 2003; Schindler et al., 2005). Thecurrent data go beyond these earlier studies in showing that this relation is exclusive.No other SUD-group had such a strong relation to any single representation. Noother group was linked to fearful avoidance. These findings are in tune with resultsfrom animal studies indicating a special role of opioids in the neuro-biologicaltransmission of attachment processes. To our knowledge, our data are the firstevidence for a special link between opioids and attachment in humans. Results donot support hypothesis that ecstasy and cannabis are used as an emotional substitutefor lacking attachment strategies. But opioids seem to be used as such a substituteand as a self-medication against attachment related distress. They seem to be themost powerful (and the most dangerous) drug for individuals without functioningstrategies of coping.

The answer to our third question is yes ostensibly. The abuse of sedatingsubstances seems to be linked to deactivating attachment strategies. Cannabis abusewas partly linked to dismissing-avoidant representations and opioid abuse waslinked to fearful-avoidant representations. But the differences between the two


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groups are important. While cannabis abuse is understood as supporting dismissingstrategies, opioid abuse is seen as an artificial deactivating strategy in fearfulindividuals. To answer the question seriously we need further research includingother sedating substances.

The answer to our fourth question is no. The abuse of stimulants was not relatedto hyper-activating strategies. We did not find a link between the stimulant ecstasyand preoccupied attachment. It seems to be too simple to equate stimulant abusewith preoccupied attachment and sedative abuse with dismissing or fearfulavoidance. Attachment representations do not seem to play a major role inexplaining ecstasy abuse.

Clinical implications

Current results hold implications for how therapy may be best approached withindividuals who have SUDs. Clearly, the current results point to the importance ofpromoting awareness of the self-mediation hypothesis, and helping individuals todevelop more secure and adaptive strategies for regulating emotion arousal.Furthermore, our data indicate a need for specialized and multi-dimensionaltreatment concepts. Especially the treatment of heroin and ecstasy-related disordershas to address multiple problems.

The treatment of heroin abuse and dependence has to interrupt addictiveprocesses and control craving and relapses. Once detoxification has been successful,opioid abusers have to learn how to regulate emotional states, how to cope withemotional distress, and how to regulate interpersonal relationships. Furthermore,treatment has to consider comorbid psychiatric disorders and the social con-sequences of SUDs. The high level of interruption of study and career paths in thecurrent sample underlines how a central goal of clinical work should be to help theseindividuals (re)discover the ordinary pleasures of study/work, and cope with theordinary frustrations of everyday life. Another difficult but crucial task is to establisha therapeutic relationship with these fearful-avoidant patients (Schindler et al., 2005;Zimmer-Hofler & Kooymann, 1996). Within the therapeutic relationship, avoidancecan be overcome and interpersonal styles can be changed. As an alternative toindividual treatment, interpersonal patterns can be addressed in a family setting.Family therapy is an effective and well-evaluated approach for substance abusingadolescents and young adults (Waldron & Turner, 2008). From an attachmentperspective, Schindler et al. (2007) have described ‘‘triangulated’’ and ‘‘insecure’’family attachment patterns in the families of substance abusing adolescents. Thesepatterns were linked to problems in developing autonomy from parents. Familytherapy can help to overcome developmental impasses and to readjust an age-appropriate balance between attachment and exploration.

The treatment of ecstasy related disorders is not less complex, but it has toaddress different problems. Detoxification and craving usually are less problematic.But treatment often has to deal with drug induced or comorbid psychiatric disorders.Psychotic states and anxiety disorders are frequent, as well as depression afterwithdrawal (Thomasius, 2000). Ecstasy abusers have pushed brain levels of serotoninto unnatural heights. Once they quit ecstasy abuse, they often go through longerperiods of depression, with major difficulties to experience positive emotions. Duringtreatment they have to (re)learn how to enjoy life without drugs. Current resultsindicate insecure attachment representations of different types. Treatment has to be


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flexible enough to respond to these different representations. The common goal isworking towards greater attachment security. As mentioned above it is important toconsider other behavioral and motivational systems than attachment.

With regard to cannabis abusers, current results hint at the motivation fortreatment as a crucial issue. Though cannabis abusers had a higher level offunctioning and relatively good coping strategies, they still met the criteria for SUDs.They abused cannabis in a way that was clinically relevant and made treatmentinevitable. Although cannabis abusers were more secure than expected, dismissive-ness was their most frequent representation; dismissing attachment is linked toavoidance of relationships and to underreporting of problems. Clinical experiencesshow that cannabis abusers do not tend to perceive problems appropriately and donot tend to ask for therapeutic support, even if it is necessary (Petersen &Thomasius, 2007). This does not make it easy to motivate them for treatment andestablish a therapeutic alliance.

Limitations

This study has several limitations that will have to be addressed by future research.First, polysubstance abuse is common today. This makes it difficult to distinguishdifferent groups of substance abusers and to find meaningful differences. Theattempt to select ‘‘pure’’ consumers of a certain substance would result in artificialgroups. So we tolerated polysubstance abuse but selected substance abusers with aclear preference for a single substance. The second limitation is the fact that ourstudy does not include other important substances such as alcohol, cocaine orbenzodiazepines. Third, we did not consider trauma and unresolved attachment,though this is of high clinical relevance. Fourth, we focused on the self-medicationhypothesis of substance abuse, leaving other variables like genetic dispositions orbehavior modeling unconsidered. Fifth, our data are cross-sectional, we do notknow, how attachment and SUDs might interact in the course of development.

Additionally there were differences between groups in age and samplerecruitment. Opioid abusers and controls were younger than ecstasy abusers. Ecstasyand cannabis abusers were recruited in nightclubs, opioid abusers were in treatmentand controls were siblings of drug abusers taking part in family therapy. However,results do not seem to be biased by one of these variables. The two younger groupswere at opposite ends of most scales. The nightclub sample of ecstasy abusers wascloser to the treatment sample of opioid abusers in several respects.

Acknowledgements

The background of this study were the research projects ‘‘Ecstasy–Eine Studie zugesundheitlichen und psychosozialen Folgen des Missbrauchs’’ [Ecstasy–a study on healthand psychosocial consequences of abuse] funded by the German Federal Department ofHealth and ‘‘Familientherapeutische Fruehintervention bei Opiatabhaengigkeit–eine vergle-ichende Querschnitts-und Verlaufsuntersuchung’’ [Family therapy with opioid dependentadolescents–a comparative cross-sectional and longitudinal analysis] funded the GermanFederal Department of Education, Science, Research and Technology (BMBF).

Notes

1. Cooper, Shaver, and Collins (1998) found secure attachment to be linked withexperimental substance use in adolescence. This substance use was related to thedevelopmental task of learning to handle culturally accepted substances.


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2. Given the high proportion of substance abusers who have experienced physical or sexualassault (Clark, Lesnick, & Hegedus, 1997; Sullivan & Farrell, 2002), unresolved state ofmind might play an important role. However, this requires a special study.

3. Inconsistent results of the AAI-studies might be due to the lack of a similar category.Lyons-Ruth, Yellin, Melnick, and Atwood (2003) reported a ‘‘hostile-helpless’’ state ofmind that might not be too far from Bartholomew’s concept of ‘‘fearful-avoidance.’’

4. Other important endogenous substances include dopamine in the limbic system as well asoxytocin and vasopressin.

5. For a detailed discussion of the different models and measures of attachment seeMikulincer and Shaver (2007), Shaver and Mikulincer (2002), Crowell, Fraley, and Shaver(1999), Bartholomew and Shaver (1998).

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heroin as an attachment substitute? differences in attachment representations between opioid,...

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