Attachment to Substance 1 Running head: ATTACHMENT TO SUBSTANCE IN PSYCHOTHERAPY RELATIONSHIPS The Impact of Attachment to Substance in Substance Dependent Individuals’ Psychotherapy Relationships: An Exploratory Mixed-Methods Study Shawn Ee Doctor of Psychology (Clinical) This thesis is presented in partial fulfilment of the requirements for the degree of Doctor of Psychology (Clinical), Murdoch University, 2017. Attachment to Substance 2 I declare that this thesis is my own account of my research and contains its main content work which has not previously been submitted for a degree at any tertiary educational institution. Shawn Ee Attachment to Substance 3 For my two little bugs, Siena and Seth. No matter how far you wander and weary you face, May you always feel like you can return to my embrace. Attachment to Substance 4 Acknowledgements Much gratitude to each client who gave consent to participate in this study, for without your generosity, patience and energies, these studies could not have been possible. I will always remember being asked by one of you to make each survey and interview count towards finding better ways to resolve these attachment issues. To Dr Helen Correia, my principal supervisor, for your perseverance and patience with me, as you have seen me through the darkest days of the write-up through to submission. You stuck it out with me despite the burnouts and driest months. Thanks for willing to entertain my life’s schedule, and providing me with seemingly endless amounts of encouragement. Your kind words and advice mean a lot to me. To Dr Pia Broderick, my original principal supervisor, who stood with me from the start, where no one else believed in this research. You always made the research process look easy and never failed to inspire me to just go for it. Whilst you could not continue the journey with me, this research is as much yours, as it is mine. To Dr Graeme Ditchburn for your invaluable feedback on the final draft. To Dr Bill Saunders, for the liberal use of your clinic and your irreverence toward the status quo. As my external research consultant, you changed my view about working with the addictions and thanks for making it all possible. You helped me find my voice. To Dr John Edwards, Junie, Jenny, and Sarah – thanks for entertaining my research at the clinic, and making me feel like I was part of the team. To Dr Marc Joffe, who delivered the initial spark for this research, and inspiring the analyst in me. My friends, of whom you are too many to name – thanks for the comradery, encouragement, and alcohol, over the years to keep this fire burning! Gratitude to my parents and in-laws for taking good care of the Nana-saur when I had to work on this. To Pap, the Bro, Adz and Aaron for the coffee runs that sustained me. Last and certainly not the least, my wife Andrea, who had to be both mum and dad for our daughter, whilst I accomplish this mammoth task. You gave me hope when there was none, and continued to cheerlead me through the ups and downs. Thanks for putting up with me, babe. Attachment to Substance 5 Abstract To date, there are no comprehensive studies that have examined the concept of attachment to substance in a substance dependent population, and how it relates to one’s attachment relationships with others. Specifically, it is unknown how an individual’s attachment to substance may influence the therapeutic relationship with their own therapist. The current research adopted a mixed-methods approach toward exploring these under-researched areas by way of collecting psychometric data with a sample of 450 substance dependent adults undergoing treatment in an anonymous survey study, and 10 individuals from that sample were interviewed in a follow-up study. Results showed that Insecure Attachment to Substance significantly influenced the relationship between one’s Attachment-Anxiety and Preoccupied-Merger attachment to therapist, providing support for the expected mediation effects. While no effect was found between Attachment-Avoidance and any style of attachment to therapist, Attachment-Avoidance was a significant predictor of Avoidant-Fearful attachment to therapist, and a significant negative predictor of Secure attachment to therapist. Men were found to have stronger associations between Attachment-Anxiety and Avoidant-Fearful attachment to therapist, when compared to women. In Study 2, all the clients interviewed experienced a Relational Dilemma, summarising their intra and inter-personal difficulties characterised by their ambivalence and insecurity, in dealing with others; and patterns of substance use. Relationally, these individuals described significant struggles leading to approach and avoidance behaviours, as a function of their personal insecurities, and these difficulties were described to manifest with their therapists. Overall, the findings supported the proposed model of Attachment to Substance, and the view that chronic and dependent substance use is an inadequate and often futile attempt to compensate for the failure to receive adequate love and care from relationships with others. Clinical implications were discussed. Attachment to Substance 6 Table of Contents Declaration 2 Dedication 3 Acknowledgements 4 Abstract 5 Table of Contents 6 List of Tables 9 List of Figures 10 CHAPTER 1 General Introduction 11 CHAPTER 2 Literature Review 2.1 Defining Substance Dependence 15 2.2 Past and Contemporary Models of Addiction 16 2.3 Disease-Concept Approach 18 2.4 Learning Theory Model 18 2.5 Addiction: A cause and result of mental illness 19 2.6 Attachment Theory 21 2.7 Adult Attachment 22 2.8 Substance Dependence as an Attachment Disorder 24 2.9 Attachment Objects 29 2.10 Attachment to Substance 32 CHAPTER 3 General Overview of the Current Research 36 3.1 The Proposed Model 3.1.1 Attachment to Parents/ Primary Caregivers 38 3.1.2 Attachment to Therapist 39 3.1.3 Attachment to Substance as a Mediator 42 3.2 Attachment to Substance of Choice Questionnaire 44 3.3 Research Aims 49 Attachment to Substance 7 STUDY 1: A SURVEY OF CLIENTS’ ATTACHMENT CHAPTER 4 4.1 Introduction 52 4.2 Methodology 4.2.1 Participants 61 4.2.2 Materials 65 4.2.3 Procedure 71 4.2.4 Data Preparation 72 4.2.5 Analytical Strategy 74 4.2.5.1 CFA Data Screen 74 4.2.5.2 SEM Data Screen and Preparation 76 4.3 Results 4.3.1 Overview of the Findings 80 4.3.2 Confirmatory Factor Analysis (CFA) of the ASCQ 81 4.3.3 Testing Mediation Effects 4.3.3.1 Measurement Model 84 4.3.3.2 Structural Model 86 4.3.3.3 Gender Comparisons 90 4.4 Discussion 91 4.5 Limitations 98 4.6 Conclusion 102 STUDY 2: A CLIENT INTERVIEW STUDY CHAPTER 5 5.1 Introduction 103 5.2 Methodology 5.2.1 Participants 109 5.2.2 Measures & Procedures 111 5.2.3 Analytic Approach to Interviews 114 5.3 Results 123 Attachment to Substance 8 5.3.1 Clients’ Unmet Emotional Needs 125 5.3.2 Clients’ Reactions to Unmet Emotional Needs 131 5.3.3 Clients’ Experience of Substance-Use 142 5.3.4 Addressing Clients’ Needs in Therapy 151 5.4 Discussion 169 5.5 Limitations 184 5.6 Conclusion 185 CHAPTER 6 General Discussion 186 6.1 Major Findings 186 6.2 Clinical Implications 187 6.3 Future Directions 192 6.4 Concluding Comments 194 References 196 Appendix 236 Attachment to Substance 9 List of Tables Table 1. Reciprocal Attachment Questionnaire (RAQ) scale Items Table 2. Brief description of ASCQ Subscales Table 3. Demographic profile of participants Table 4. Description of participants by family history of dependence issues Table 5. Description of participants by history of substance use and substance of choice Table 6. Description of participants by current treatment-related information Table 7. Attachment to Substance of Choice Questionnaire (ASCQ) scale items Table 8. Skew and kurtotic values of the measured variables Table 9. Brief description of the derived scale: Insecure Attachment to Substance Table 10. Factor Loadings for the Measurement Model Table 11. Correlations Among Latent Variables for the Measurement Model Table 12. Path coefficients for the Structural Model Table 13. Client demographics and history of substance use Table 14. Higher order (Organising) themes and sub (Basic) themes Table 15. Clients’ individual scores on the ASCQ, SDS and CATS questionnaires Attachment to Substance 10 List of Figures Figure 1. Schematic of the proposed model of attachment to substance Figure 2. Hypothetical Model Figure 3. Prisma Flow Diagram of participants approached, participated, discontinued Figure 4. Path diagram of the 12-item ASCQ presented with standardised parameter estimates Figure 5. Hypothesised model with standardised path coefficients and item parcels Figure 6. Standardised coefficients using the causal steps approach for demonstrating mediation Figure 7. Initial thematic map Figure 8. Developed thematic network displaying Global, Organising and Basic Themes Figure 9. Final thematic network Figure 10. Thematic sub-network for “Clients’ Unmet Emotional Needs” Figure 11. Thematic sub-network for “Clients’ Reactions to Unmet Emotional Needs” Figure 12. Sub-network of shared theme “Coping with Emotional Self-Regulation Difficulties” Figure 13. Thematic sub-network for “Clients’ Experience of Substance-Use” Figure 14. Thematic sub-network for “Addressing Needs in Therapy” Figure 15. Final thematic network depicting the salient themes Attachment to Substance 11 CHAPTER 1 General Introduction Treating addiction or substance dependence is a challenging and often daunting task, which includes macro level, socio-political ramifications accompanied by a host of primary and secondary costs of substance abuse that can impact planning and treatment service provision (D. J. Collins & Lapsley, 2008). A 2008/09 report on alcohol and other drug treatment services in Australia (H.