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What is the link between insecure attachment, alexithymia and addiction in
adolescence and the psychotherapeutic treatment options available?
Page 2 – 3: Introduction
Page 3 - 5: Attachment
Page 5 – 9: Affect regulation and alexithymia
Page 9 – 10 Alexithymia and attachment in adolescence
Page 10 – 14: Addiction
Page 15 – 16: Psychotherapeutic treatment interventions in adolescence
Page 18 – 20: Conclusion
Page 21 – 27: References
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What is the link between insecure attachment, alexithymia and addiction in
adolescence and the psychotherapeutic treatment options available?
Introduction
This extended literature based exploration will look at the subject of insecure attachment,
alexithymia and addiction in adolescence and psychotherapeutic treatment options available.
The reason for my choosing of this subject matter is because of my own personal
experience with relational attachment difficulties with my primary caregiver as a child and the
subsequent addiction issues I struggled with as a young person and adult. As a trainee child
and adolescent psychotherapeutic counsellor, and person in long term recovery, I am also
increasingly aware of my own struggles with alexithymia and this created a wondering as to
whether there was a link between insecure attachment type, alexithymia and addiction that
starts in adolescence and persists into adulthood? The larger question that this then
prompts, which is too big for this piece of work, is if I had experienced restorative relational
therapy as an adolescent and been able to work on and overcome my alexithymia would my
addiction have been stopped from developing or reduced in severity? Within this
assignment I will explore and critique the literature around the three distinct subjects of
insecure attachment, affect regulation and alexithymia and addiction in adolescence and
how one may lead to and influence the other. Then I will explore the psychotherapeutic
treatment interventions currently available and look at potential future areas for research
development and any study limitations. I am aware of extensive literature looking at the
subjects in adults but was less aware of research pertaining to children and adolescents so
this study is both to inform you and help me learn more about this specific and important, but
apparently under researched, area of psychotherapeutic counselling need. It feels
appropriate to focus first on attachment and then affect regulation and alexithymia and the
relationship between the two and then finally on addiction and how alexithymia impacts this
issue in adolescence before the treatment interventions and conclusion.
Literature searches were carried out on PsycINFO using the search terms, insecure
attachment and addiction, insecure attachment & alexithymia and alexithymia and addiction.
Books searches were done at the Education Library regarding affect regulation. Emails
were sent to key researchers in the field asking for their input and an approach was made to
the local Child and Adolescent Substance Abuse Service (CASUS) for Cambridgeshire.
This is an increasingly rare and unusual Child and Adolescent Mental Health Service
(CAMHS) but I had been lucky enough to have some training from them in a former role so
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had their contact details. All were hugely helpful and supportive with their time and advice
which I have included as part of this literature review. As a person in long term recovery
from substance misuse I already owned some of the key texts and had read around the
subject as part of my recovery process. So with that in mind I will first review attachment
looking particularly at insecure attachment.
Attachment
It is both interesting to me and informative that attachment theory has formed a thread that
has woven itself through all the three pieces of work I have completed this year as part of my
Post Graduate Diploma with the University of Cambridge. It suggests that I am still actively
working on understanding the impact that this has had on me both personally and in terms of
its resonance for the young people I will meet as a child and adolescent counsellor. Its
importance within child and adolescent psychotherapeutic counselling should not be
underestimated. That said there has been an ongoing debate within psychology regarding
nature vs nurture as discussed by Sroufe and Siegel in their paper ‘The verdict is in – the
case for attachment theory’ (2011). Within this piece of research they curated many of the
‘hard-nosed academics and researchers who’ve remained unconvinced’:
‘Back in 1968, psychologist Walter Mischel created quite a stir when he challenged
the concept that we even have a core personality that organises our behaviour,
contending instead that situational factors are much better predictors of what we
think and do. Some developmental psychologists, like Judith Rich Harris, author of
The Nurture Assumption, have gone so far as to argue that the only important thing
parents give their children is their genes, not their care. Others, like Jerome Kagan,
have emphasised the ongoing influence of inborn temperament in shaping human
experience, asserting that the effect of early experience, if any, is far more fleeting
than is commonly assumed.’
So attachment theory, what is it? The central tenet of attachment theory is that babies and
children learn about the world in a relational way. Bowlby (1973, 1988) believed that it was a
child’s relationship with their primary care giver that set the template in their minds about
how relationships worked. This template is known as the ‘internal working model’ (IWM).
The IWM has three elements: a model of self, a model of ‘other’ and a model of the
relationship between these.
Another attachment researcher and theorist Mary Ainsworth then developed the attachment
theory further by identifying the three different types of attachment categories and
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developing a standard method for assessing attachment in infants aged around 1 year old,
known as the Strange Situation. This became the ‘gold standard’ laboratory technique for
attachment research (Ainsworth et al, 1978) still now widely used to study the influences on
attachment and its developmental consequences. Ainsworth observed that, although there
were some important differences in how children behave when they are separated from their
mothers, it was during reunions after separations that differences between children’s
behaviour were most evident.
According to attachment theory, these three different types of attachment category show the
main forms that a child’s IWM can take and are divided into. These different types are:
insecure avoidant attachment (Type A), secure attachment (Type B) and insecure
ambivalent attachment (Type C). A fourth category was also added by Main and Solomon
(1990) called disoriented or disorganised attachment (Type D). Each type of attachment is
associated with a different IWM of self, other and the relationship.
Because it was believed that IWM’s were enduring beyond childhood and continuous across
generations, there was an expectation of an association with an adult attachment type. An
Adult Attachment Interview (AAI) was developed by Main and others (George et al, 1985,
Main and Goldwyn, 1994) to assess an adult’s ability to integrate early parental relational
memories into an overarching working model of relationships. The narratives for each type
of attachment were therefore predicted to align with the attachment type and fell into one of
three narrative categories, classified as dismissing, autonomous or pre-occupied. The
logical predictions were that Type A insecure avoidant presented with a dismissing narrative
and therefore adult attachment classification, Type B secure attachment with an autonomous
narrative and Type C insecure ambivalent with a pre-occupied narrative. Because this
literature review focuses on adolescents it is important to highlight that there is an
adolescent version of the Attachment Style Interview (ASI) (Bifulco, Moran, Ball, &
Bernazzani, 2002), an investigator-based interview which uses a contextualised, support-
focused approach to assess current interpersonal behaviour and attitudes.
Within this piece of work I am going to focus on the Type A insecure attachment type as this
reflects my attachment style as to try to explore all types of attachment is beyond the word
limit of this research review. With an insecure attachment bond the IWM consists of
negative representations of the self and the other and therefore hampers the development of
self-confidence and emotional-regulation (Oskis et al, 2013). These adolescents expect
unavailability or insensitivity from their primary carers and consequently develop insecure
strategies of either avoidance or anxiety for trying to cope with their distress (Mallinckrodt &
Wei, 2005). These strategies could be considered ‘self-soothing strategies’ and are
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misguided attempts to organise affects and internal states meaningfully (Goodsitt, 1983) and
this definitely resonates with my experience. The personal therapist I have had this past
year is a specialist in family, trauma and addiction and her role and therapeutic presence
have been vital in my own reparative work around attachment. She has consistently role-
modelled a secure attachment so that I have been able to learn to relate and experience
this. I am confident that this will help my ability to provide a restorative relational presence
around the children and adolescents that come to see me as a trainee child and adolescent
counsellor as it has already begun to impact on my relationship with my own children.
When looking at attachment and addiction there was an excellent review on attachment and
adolescent substance misuse which looked at the empirical evidence and implications for
prevention and treatment. By Schindler and Broning it was published in 2014 and
recognised that to date the role of attachment in developing substance use problems is
understudied therefore research linking insecure attachment with Substance Use Disorder
(SUD) is limited. They also acknowledge that interventions for SUD in adolescence are of
special importance because they can help to prevent long-lasting addictive disorders and so
supported my initial wondering.
They define attachment as a ‘motivational, behavioural, and interactional system that
provides security’ (Schindler & Broning, 2014). At the same time, this security in attachment
is the base for explorations of both the external world and the child’s own inner world and
that of others, therefore learning the ability to ‘mentalize’ (Bateman and Fonagy, 2012) and
for gaining a coherent picture of mental processes. Within attachment at adolescence
Schindler and Broning report that ‘longitudinal as well as cross-sectional studies have shown
that dismissing-avoidant attachment is linked to externalizing disorders, whereas
preoccupied attachment in adolescence is linked to internalizing disorders’ (2014). They
report that recent multilevel analyses have identified 2 prototypic pathways to SUD. The
externalizing pathway (Zucker et al, 2011) is characterised by a tendency toward disinhibited
behaviour leading to risk-taking behaviour in adolescence. The internalizing pathway
(Hussong et al, 2011) is characterised by impaired emotion regulation capabilities from early
childhood on, possibly leading toward the desire to self-medicate when facing negative
affect. They found that all studies in the review showed a link between insecure attachment
and SUD and concluded that meta-analytic calculations and 2 longitudinal studies show that
insecure attachment was a risk factor for substance abuse. They argued that the closeness
of attachment and substance abuse was also ‘underpinned by animal studies, which showed
that psychotropic substances (especially opioids) had a strong impact on brain circuits
regulating attachment processes’. Based on this data they felt that substance abuse in
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adolescence could be understood as an attempt to regulate affective states, as a means of
self-medication for individuals with insecure attachment.
Research by Schore & Schore (2008) argued that Bowlby’s fundamental goal was the
integration of psychological and biological models of human development. In their words:
‘The recent interest in affective bodily-based processes, interactive regulation, early
experience-dependent brain maturation, stress, and nonconscious relational
transactions has shifted attachment theory to a regulation theory. This emphasis on
the right brain systems that underlie attachment and developmental change has in
turn forged deeper connections with clinical models of psychotherapeutic change, all
of which are consonant with psychoanalytic understandings.’
Thorberg et al (2010) argued that attachment theory could be conceptualised as an affect
regulation theory also, proposing that attachment was associated with the expression and
recognition of emotions as well as interpersonal functioning. In the words of Kraemer and
Loader (1995) from the Tavistock, London: ‘An insecure attachment may lead to a failure to
learn how to feel, setting the stage for an alexithymic personality.’ Further research by
Thorberg et al (2011a) completed the first meta-analysis of parental bonding and alexithymia
and their findings confirmed an especially strong association between maternal care and key
elements of alexithymia. Attachment theorists regard affect regulation and the quality of
attachment as closely linked so this is what I will explore next – affect regulation and
alexithymia.
Affect regulation and alexithymia
My academic joining of the interlinking subjects of affect regulation and alexithymia feels
primitive and unsophisticated and reading some of the literature around the neurobiology of
attachment I feel very out of my depth at times. Stephen Porges in The Polyvagal Theory
(2011) draws on many other researchers linking the right hemisphere with the expression,
interpretation and regulation of emotion and cites several investigations that have argued the
right hemisphere provides the primary control of emotion. One such survey of studies by
Silberman and Weingartner (1986) suggested superiority of the right hemisphere in
recognising emotional aspects of stimuli. They proposed that right hemisphere dominance
for emotion regulation reflected a nervous system organisation that gave priority to
avoidance or defensive mechanisms that had a high survival value. Porges also argues that
vagal tone and the vagal system might provide a ‘physiological metaphor’ (Porges, p143) for
the regulation of emotional states as show in the study of 3 month old infants by Huffman et
al (1998). The polyvagal theory of emotion proposes that ‘the evolution of the autonomic
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nervous system provides the organizing principle to interpret the adaptive significance of
affective processes.’ (Porges, p 152)
Schore’s interpretation helps build on my understanding of Porges’ work providing further
windows of insight that help light the way as this summary shows:
‘In keeping with the principle that the right hemisphere develops before the left, the
early language that appears in the second year represents the output of the right
hemisphere. The socioaffectively-driven expansion of language in the service of the
right hemispheric cognition thus mediates the development of self-regulation through
private speech that is, thought. Thought originates in silent imaginal dialogs that
represent the child’s autobiographical narrative construction of his affective
transactions in the world. Maternal stress regulating verbalizations are also
internalised into the multi-modal interactive representations that encode the self-
caring functions of evocative memory. The child who is deprived of such affective
communication experience in this critical period is in danger of developing the
regulatory disturbance of alexithymia’ (Schore, p489).
So for me my primary care-givers negative and angry responses to my expressions of self
and my needs, cognitively and affectively encoded for me a physiological and emotion
message that I was not wanted and a nuisance. This translated into a negative sense of self
and inability to self-care because I believed I was not good enough. But equally I was
unable to express this because I did not have the words and felt I didn’t have the right to
express it and was left unable to self-sooth this as I had not been role-modelled this either.
Hence I related in an anxious and avoiding manner because this felt safer. Schore goes on
to say:
‘Taylor (1987) concludes that deficiencies in the early mother-infant relationship
result in an alexithymic deficit associated with a limitation of symbolic function and an
impaired capacity for self-regulating emotional states and physiological functioning
when under stress. It is tempting to speculate that this relational environment also
generates high levels of unregulated shame, and that shame, an affect that uniquely
causes a 'loss of words' (Izard, 1991) always accompanies alexithymic syndromes’
(Schore, p485).
This resonated very strongly with me and expressively encapsulates my felt sense of shame,
creating a loss of words which is both a feature of alexithymia and a result of traumatic early
attachment relationships. Schore goes on to quote researcher’s such as Kaufman (1992)
who argued that shame can ‘bind individual affects such as fear, distress, anger or even
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positive affects’. To me this suggested that those that had had some positive relational
experiences in their early attachment relationships may have developed what he called
‘focal’ alexithymic deficits where specific affects were ‘silenced’ and could not be identified
and verbally labelled. I feel this strongly around the emotion of anger in particular as this
was not a tolerated emotion in my family of origin in its direct expression and therefore was
expressed in a more damaging passive-aggressive manner. I have been reclaiming the
ability to express healthy anger during personal therapy as part of my own re-connecting
with my previously alexithymic self. Schore expressed this so eloquently by quoting
Kaufman (1992) as saying ‘returning internalised shame to its interpersonal origin with an
empathetic focus on the child who experienced it’. I am hoping to mirror this empathetic
focus in my practice as a trainee child and adolescent counsellor as it has been role-
modelled to me in personal therapy.
So what is alexithymia? De Haan (2012) writes that alexithymia refers to the difficulty in
identifying and describing feelings, the inability to discriminate between feelings and physical
sensations, having a limited fantasy life and the inclination to an externally oriented way of
thinking (Sifneos, 1973). Externally oriented thinking can be described as concrete, realistic,
logical thinking, often to the exclusion of emotional responses to problems, and is resonant
of the dismissing narrative identified in AAI and linked to the avoidant attachment style.
Alexithymia is typically measured using the Toronto Alexithymia Scale (TAS-20; Bagby,
Parker, & Taylor, 1994) which worldwide is the most frequently used assessment instrument.
It includes three factors: (1) difficulty in identifying feelings (DIF), (2) difficulty in describing
feelings (DDF) and (3) externally oriented thinking (EOT) (Bagby et al, 1994). There is an
alexithymia questionnaire for children, which is based on the original Toronto Alexithymia
Scale 20 that assesses alexithymia in adults. The Alexithymia Questionnaire for Children
consists of 20 items that represent the same three factors with the item response format
being: not true, a bit true, true (Rieffe et al, 2006).
There has been some critical evaluations of the validity and reliability of the TAS-20 scale
(Kooiman et al, 2002). Thorberg et al (2016) considers it a trait-like risk. Other researchers
such as de Haan et al (2012) consider it not a stable personality trait and ask the question
‘state or trait?’ Bagby and Taylor went on to suggest that there may be two kinds of
alexithymia, 'primary alexithymia' which is an enduring psychological trait which does not
alter over time, and 'secondary alexithymia' which is state dependent and disappears after
the evoking stressful situation has changed. These two manifestations of alexithymia are
otherwise called 'trait' or 'state' alexithymia (Taylor, 1997 p37). The researchers concluded
that the findings suggested that alexithymia in SUD patients is both a state and trait
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phenomenon (de Haan, 2014). A multimodal investigation of emotional responding in
alexithymia by Luminet et al (2004) describes ‘the personality construct of alexithymia is
thought to reflect a deficit in the cognitive processing and regulation of emotional states.’
They found that facets of the alexithymia construct were associated with lower emotional
responses at the cognitive-experiential level, but with higher emotional responses at the
physiological level as measured by heart rate, which also resonates with Porges Polyvagal
Theory.
This raised the question in my mind that if alexithymia can be considered both an emotional
stress state and stable personality trait how does this fit with attachment theory? The TAS-
20 uses psychometric testing and how does this assess attachment which is a relational
phenomenon rather than an individual difference which personality trait is. Research by Abe
and Izard (1999) completed a longitudinal study looking at emotion expression and
personality relations in early development. They discussed just this issue acknowledging
that it had generated considerable debate in developmental psychology. The question
remains whether emotion expressions elicited during the strange situation procedure
indexes individual differences in security of attachment or in temperament (e.g. Cassidy,
1994; Kagan, 1982; Sroufe, 1985; Vaughn et al., 1992). For me this remains a limitation as
does the TAS-20 requiring some level of emotional insight to be able to complete as a self-
report measure.
Alexithymia and attachment in adolescence
Research by Oskis et al (2013) was the first to look at alexithymia in female adolescents and
the role of attachment style. This British study of 60 females ranging in age from 9 to 18
years found that features of anxious and avoidant insecure attachment styles were
differentially related to the separate facets of alexithymia. Their research findings reported
that the avoidant attachment style characteristic of constraining closeness predicted more
difficulty in describing feelings (DDF) and having higher levels of the anxious characteristic
of fear of separation predicted greater difficulty in identifying feelings (DIF). A more marked
felt attachment to mother predicted less externally oriented thinking (EOT) and age was a
significant independent predictor of overall alexithymia levels, as well as EOT. They found
‘of all the attachment style attitudes, fear of separation was the only significant independent
predictor of total levels of alexithymia’ (Oskis et al, 2013). Once more my felt experience
resonates with this finding as I experienced abandonment at around 9 months and therefore
had a fear of separation which probably exacerbated my level of alexithymia. This research
closely corresponded with earlier research by Meins et al (2008) where distance from
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attachment figures would result in reduced emotional interaction and descriptions because
there would be simply less opportunities to share emotional experiences. Therefore their
findings were consistent with the view that ‘attachment avoidance involves constraining and
deactivating emotional responses and evaluations’ (Griffin & Bartholomew, 1994). Oskis et
al (2013) commented that ‘the constant act of thinking of oneself in relation to another, which
is characteristic of fear of separation, would expectedly produce difficulty in identifying one’s
own feelings’ and this feels like a true reflection of my experience. They conclude that their
research indicates that features of anxious and avoidant insecure attachment styles are
differentially related to the separate facets of alexithymia in adolescents. In particular, the
findings concerning the anxious attachment construct of fear of separation may reflect the
adolescent struggle for autonomy and the consequent effects on the affect regulation
system. Which causes me to question whether this struggle for autonomy is part of the
‘normal’ developmental tasks of adolescence or whether this is a heightened struggle?
Having looked at the impact on female adolescents I then tried to find research to support
the male perspective. I could only find one Italian study where they had researched insecure
attachment and alexithymia in 100 young men with mood symptoms. Troisi et al’s (2001)
sample group had a mean age of 20.3 years which indicated older adolescents within the
cohort. They found that alexithymic traits were more pronounced in those with patterns of
insecure attachment and who reported more severe symptoms of separation anxiety during
childhood. Among the subgroup with insecure attachment styles, those with a preoccupied
or fearful attachment style had a higher prevalence of alexithymia (65% and 73%,
respectively) than those with a dismissing pattern (36%). Therefore their data suggested a
role for early developmental factors in the aetiology of alexithymia. Having considered affect
regulation and alexithymia I will now move on to looking at addiction, or substance misuse,
as it is more commonly referred to currently.
Addiction
What is addiction? Foote et al (2014) in Beyond Addiction – A Guide for Families cite the
Merriam Webster definition of addiction which is ‘a compulsive need for and use of habit-
forming substance characterised by tolerance and by well-defined physiological symptoms
upon withdrawal’ (p27). I would add from my experience that the withdrawal symptoms can
be psychological and there is a set of affective symptoms frequently recounted within the
recovery community called Post-Acute Withdrawal Syndrome (PAWS). Koob (2000) in his
paper Neurobiology of Addiction describes that ‘withdrawal from drugs of abuse is
associated with subjective symptoms of negative affect, such as dysphoria, depression,
irritability and anxiety, and dysregulation of brain reward systems involving some of the
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same neurochemical systems implicated in the acute reinforcing effects of drugs of abuse’
which he argues is why ‘drug addiction is a chronic relapsing brain disorder characterized by
neurobiological changes that lead to a compulsion to take a drug with loss of control over
drug intake’. Also ‘animal models of craving involve not only conditioning models but also
models of excessive drug intake during prolonged abstinence, post-acute withdrawal, that
may reflect continued dysregulation of drug reinforcement that could lead to vulnerability to
relapse’. Tommy Rosen in his book ‘Recovery 2.0’ (2014) defines addiction as ‘any
behaviour you continue to do despite the fact that it brings negative consequences into your
life’ (p3). This is why I feel resolution of this in adolescence would be such a powerful
therapeutically beneficial outcome.
So before we move on to discuss the inter-relation of attachment, alexithymia and addiction I
wanted to discuss the prevalence of substance misuse with the UK adolescent population
and to ascertain this I have consulted the Association for Young People’s Health (AYPH)
2015 key data which is produced with the support of the National Child and Maternal Health
Intelligence Network and Public Health England. As regards alcohol consumption they
report that the latest data suggests that 61% of those aged 11-15 say they have never drank
alcohol. Around one in eleven (9%) reported that they had drank alcohol in the last week and
the majority of those were 14 and 15 years old of which there were slightly more males than
females (25% compared with 19%). The average number of units drunk by those pupils
aged 11-15 who drank in the last week has fluctuated in recent years although the overall
trend has been down from 16 to 10 units in males and 13 to 9 units in females. This is the
lowest rate at any time since the SDDU survey began in1988 (HSCIC, 2014c).
Of note their data stated that ‘being drunk is a key indicator of alcohol misuse. HBSC reports
that among the 10% of 15 year olds in the study who report being weekly drinkers, 83% of
the boys and 57% of the girls had been drunk ten times or more in the last month’ (Hagell et
al, 2015). This suggests there is a small group of young people who are not following the
general trend of reducing consumption.
In older adolescents (16-24 years) according to the Opinions and Lifestyle Survey (OLS) in
2012 half of the age group (50% of men and 48% of women) reported drinking in the last
week with two per cent drinking on five or more days in the week. However there is
evidence of a fall over time in regular drinking in this 16-24 age group (Hagell et al, 2015)
They reported there was a considerable amount of data relating to substance and illegal
drug use among young people and that overall, there had been a downward trend, with a fall
from 41% to 26% for males, and from 36% to 22% for females. Concern often centred on
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young people and polydrug usage as an indicator of particularly problematic use, although
the data suggested that cannabis on its own was the most common drug used.
Flores (2004) argues that addiction was an attachment disorder. Gabor Mate (2008)
believes that substance addictions are an attempt to self-medicate emotional pain – but he
says importantly more than that, brain development was sabotaged by traumatic
experiences such as poor attachment experiences with early care-givers. He also believes
that addiction is a deeply ingrained response to stress in early life, an attempt to cope with it
through self-soothing. He says ‘maladaptive in the long term, it is highly effective in the short
term’ (Mate, p198). Interestingly research by Suh et al (2008) looked at how the type of drug
chosen represented the need to address a particular impairment in affect regulation (Flores,
2004). Emotional repression was associated with alcoholism, restlessness predicted
cocaine preference, and more angry or negative behaviour was predictive of heroin use.
Thus, Fletcher (2015) argued that the aetiology of addictive behaviour could arguably begin
with an unmet need that fuels an individual’s attraction to a particular substance. Again my
lived experience supports this statement and resonated very strongly. I attempted to numb
and manage difficult emotions that I experienced around my primary care-giver with alcohol
because environmentally that is what I had learned and had been role-modelled to me but
equally because it was so effective in anaesthetising any felt sense attached to those
thoughts, feelings and emotions. It allowed emotional repression for me. As alcohol is a
legal, widely and readily available socially sanctioned drug I worry that this makes it an easy
salve for emotionally discordant adolescents and so there is a need to ensure that we as
trainee child and adolescent counsellors are aware of its potential to create further
dysregulation for the young people who require our services.
Gabor Mate also writes about addiction:
‘The three dominant brain systems in addiction – the opioid attachment-reward
system, the dopamine-based incentive-motivation apparatus and the self-regulation
areas of the prefrontal cortex – are all exquisitely fine-tuned by the environment. To
various degrees, in all addicted persons these systems are out of kilter. The same is
true, we will see, of the fourth brain-body system implicated in addiction: the stress-
response mechanism’ (Mate, p188)
Gabor Mate cites the Felitti et al (1998) published landmark research – the US Adverse
Childhood Experiences (ACE) study which had a cohort size of 9367 women and 7970 men
in which they found that:
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‘Overall these studies provide evidence that stress and trauma are common factors
associated with consumption of alcohol at an early age as a means to self-regulate negative
or painful emotions.’ (Dube et al, 2002)
And these were within a relatively healthy and stable adult population where one third or
more were graduates of college and most had at least some university education. With this
in mind the literature reviewed has been mainly on adults as there is very little research on
addiction in adolescence as regards substances, notably studies on cannabis usage in
adolescents and young adults (Dorard et al, 2008) although there are increasing amounts of
research on behavioural addictions, such as internet usage in late adolescents (Schimmenti
et al, 2015)
Thorberg et al (2016) describes alexithymia as a trait-like risk factor for the development of
alcohol use disorders. It is considered an affect-regulation disorder with a prevalence of up
to 67% in alcohol-dependent populations (Taylor, Bagby, & Parker, 1997; Thorberg, Young,
Sullivan, & Lyvers, 2009). He goes on to say that ‘few studies have investigated the
absolute (whether mean scores change over time) and relative (extent to which relative
differences among individuals remain the same over time) stability of alexithymia among
men and women with alcohol dependence, or have considered potential underlying
mechanisms’. Research by De Rick and Vanheule (2007) looked at the understudied
relationship between perceived parenting, adult attachment style and alexithymia in a group
of 101 alcoholic inpatients and observed that the avoidant attachment style was a strong
predictor. They also tested whether three dimensions of alexithymia--affective, cognitive and
social--were meaningfully linked to adult attachment and perceived parenting and noticed
that cognitive alexithymia especially was predicted by the avoidant attachment style and a
lack of warmth perceived in the relationship to the father.
Equally research by Thorberg looks mostly at alcohol use disorders and in the discussions
he comments that comparatively other research in a psychoactive substance-dependent
population revealed no mean changes in TAS-20 total DIF, DDF, and EOT scores (Pinard et
al, 1996). Alexithymia’s presenting difficulties in identifying emotional states, distinguishing
emotions and sensations, and expressing emotions using words (Sifneos, 1973) means it
appears to be over-represented among subjects with substance-use disorders. Interestingly
an Australian piece of research by Lindsay & Ciarrochi (2009) found that within their group of
40 adult newly abstinent substance abusers they reported having a deficit in emotional
processing or alexithymia. However their actual performance on a task that required them to
identify and describe feelings was not significantly different from either a group of university
students (after controlling for IQ, age, and gender) or a normal group of adults. In addition,
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there was no relationship between self-reported and actual emotional processing
performance, which is contrary to what has been found in a normal sample leading them to
conclude that substance abusers believe they are more alexithymic than others, but do not
perform as if they are so.
A French study by Bonnet et al (2013) hypothesised that ‘it was possible that negative
emotionality may lead to ‘use’ of alexithymia to alleviate negative emotions and that such a
use of alexithymia may predict substance use’. The goals of their study were to confirm
previous findings on the relationship between emotionality (negative emotionality and
emotional arousal), alexithymia and substance use in young adults. The study looked at 256
university students with a mean age of 20.7 years old and found that their statistical
analyses indicated positive links between the emotional dimensions of alexithymia, DIF and
DDF, and substance use. The more difficulty individuals reported identifying and describing
their emotions, the greater the likelihood of reporting substance use. Their findings stressed
the importance of both of the emotional dimensions of alexithymia in substance use which
seemed to correspond to the manner in which substance ‘consumers’ process their feelings,
and have often been observed in studies of addicted patients (Speranza, Corcos, Stephan,
Loas, Pérez-Diaz, Lang, et al, 2004). Emotion regulation can be useful in maintaining a form
of psychic homeostasis which resonated for me with Porges Polyvagal Theory discussed
earlier.
Professor Fred Thorberg is one of the key researchers into insecure attachment, alexithymia
and alcohol use disorders in young adults having researched, written and published 20
papers in the last ten years. He argues that previous research had reported affect regulation
difficulties in SUD and addiction has been considered an attachment disorder. However, he
goes on to say that scarce empirical research exists on the relationship of attachment in
relation to affect regulation and interpersonal functioning in those with substance use
problems (Thorberg, 2010). He believes it is associated with an increased risk and severity
of alcohol-related problems (Thorberg, Young, Sullivan, & Lyvers, 2009) and acknowledged
there were several studies that had examined alexithymia in association with other risk
factors for alcohol use including attachment.
Thorberg acknowledges that attachment difficulties are a key risk factor for the development
of alexithymia and his research in 2011(b) looked at a sample size of 210 adult outpatients
where they found significant relationships between anxious attachment and alexithymia
factors. The research also highlighted that alexithymic alcoholics reported significantly higher
levels of anxious attachment and significantly lower levels of closeness (secure attachment)
15
compared to non-alexithymic alcoholics. They felt that these findings highlighted the
importance of assessing and targeting anxious attachment among alexithymic alcoholics in
order to improve alcohol treatment outcomes.
He also completed an extensive critical review in 2009 of all the literature that had been
written pertaining to alexithymia and alcohol use disorders where he noted that several
authors have proposed that insecure attachment and alexithymia were broad risk factors for
the development of alcohol dependence (Haviland et al., 2000, Taylor et al.,
1997 and Vungkhanching et al., 2004). He also expressed that contemporary attachment
theory considers addiction an attachment disorder (Flores, 2004) and evidence indicated
that insecure attachment was associated with harmful drinking patterns (Brennan and
Shaver, 1995, Burge et al, 1997, Cooper et al, 1998 and Ognibene and Collins, 1998) and
alcohol dependence. He went on to say that alexithymic individuals were possibly using
alcohol as a coping mechanism for emotional self-regulation (De Rick and Vanheule, 2007b,
McNally et al, 2003, Thorberg and Lyvers, 2006 and Vungkhanching et al, 2004). De Rick &
Vanheule, (2007b) found that alcohol dependent individuals with insecure attachment
reported higher levels of ‘difficulties communicating their feelings’ compared to a more
securely attached group.
Psychotherapeutic treatment interventions in adolescence:
The most elucidating research was that by Schindler and Broning. This was because not
only did they share empirical evidence that strongly supported the assumption of insecure
attachment in samples of adolescent substance abusers but because they went on to
consider implications for treatment and prevention. These supported, confirmed and went
beyond my instinctively hypothesised intervention ideal in the introduction.
Schindler and Broning felt treatment outcome should benefit from fostering attachment
security so as to mirror a secure attachment. They recognised that adolescence was the
most promising target age for early interventions that could prevent the development of long-
term SUD.
They then outlined three basic approaches to integrate attachment aspects into state-of-the-
art treatment of SUD:
1. The therapeutic alliance can be established in a way to become a correcting
relationship experience that helps to develop more attachment security. This will
often require specific engagement strategies that have to be adapted to the specific
pattern of attachment.
16
2. Attachment-based approaches of individual treatment should be adopted for the
treatment of SUD. To date, the most promising approach is Mentalization-Based
Therapy (MBT, Bateman & Fonagy, 2012). This is exactly the approach used by
CASUS in Cambridgeshire as when I approached the service their Consultant
Psychiatrist shared with me their resources, which in the UK includes Adolescent
Mentalization-Based Integrative Therapy (AMBIT, Bevington, 2012). These
approaches focus on the vicious circle between insecure attachment, anxiety, and
other negative emotions, a subsequent loss of mentalization, and substance abuse
as a self-medication.
3. Family therapy approaches are of special importance. The family of origin is where
attachment relationships develop and can most easily be transformed. Family
therapy approaches for adolescent substance abuse are among the best-evaluated
treatments (Rowe, 2012; von Sydow et al, 2008)
They went on to outline two other explicitly attachment-based approaches, which had not at
that time been used in the field of adolescent substance abuse: Mentalization-Based Family
Treatment (MBFT, Asen & Fonargy, 2012) and Attachment Based Family Therapy (ABFT,
Diamond et al, 2008). MBFT promotes mentalization in a family context and works in an
attachment theory framework combined with family therapy setting. ABFT tries to re-
establish lost emotional contact between depressed and suicidal adolescents and their
parents and might be more easily adapted for youths on an internalizing pathway. It seems
very possible to integrate aspects of MBFT and ABFT into family therapy approaches
designed for adolescent substance abusers.
I was delighted to hear that AMBIT was being used locally within the CASUS team.
Research by Bevington et al (2013) developed this approach for their ‘hard to reach’ young
people who often presented with co-morbid mental health issues and may also have
substance use disorders. AMBIT is described as an emerging team-based approach to
working with highly troubled adolescents and young adults (Bevington & Fuggle, 2012;
Bevington, Fuggle, Fonagy, Asen, & Target, 2012) that draws on and applies attachment
theory at a number of levels. AMBIT is a mentalizing approach and as with other systemic
approaches looks to nurture and scaffold existing constructive family or peer relationships
and resiliencies in the young person’s life.
The researchers used the term mentalization in the sense used by both neuroscience (Frith,
2007) and psychological therapy (Bateman & Fonagy, 2011), to refer to a form of
imaginative mental activity about others or oneself, namely, perceiving and interpreting
human behaviour in terms of intentional mental states (e.g. needs, desires, feelings, beliefs,
17
goals, purposes, and reasons). They argue that mentalizing – the function of coming to
understand and communicate about behaviour (one’s own or that of others) in mental state
terms is born in the context of an attachment relationship and is the key to social
communication and the gathering of social information (Fonagy, Luyten, & Strathearn, 2011).
A strong body of evidence (Fonagy, Gergely, Jurist, & Target, 2002) supports the notion that
mentalizing is not a biologically heritable function. Bevington et al (2015) maintain that:
‘It develops in the context of attachment relationships, through a process whereby the infant
iteratively experiences his/her own mental states being accurately understood and
communicated by a trusted other, via imitative facial and verbal gestures. Through
experiencing this other mind being changed through contact with (and understanding of)
one’s own mind, self-agency, and mind-mindedness (of both one’s own and of others’
minds) develops’.
Within AMBIT robust outcome measurements are expected as a core part of practice, and
tools are integrated within the manual as the ‘AMBIT Adolescent Integrative Measure’ (AIM)
A goals-based approach to routine outcomes monitoring using the AMBIT AIM was started in
2012 in Cambridgeshire CASUS with some preliminary promising results. An uncontrolled
pilot evaluation of 63 key problems identified at start of treatment in 15 cases indicated that
79% showed improvement at discharge, with 9 cases rated as having occasional or no use
of alcohol or drugs at case closure.
I was also heartened to see that AMBIT is an ‘OpenSource’ approach to therapy and is
strongly opposed to the notion that effective ways of working with adolescents could be
turned into intellectual property or commodities. The AMBIT manual is freely available, and
is built on developments from a wide range of fields. There are parallels between the
OpenSource model of software development in computing and many of the ways that AMBIT
is conceived of operating. The radical and award winning approach to treatment
manualization encourages the development of local expertise and a ‘community of practice’
between the different teams using it, who can make use of ‘comparing and sharing’ functions
in their locally adapted versions of the core AMBIT content (AMBIT, 2012) The notion that
the work of Cambridge could benefit ‘hard to reach’ young people including those with
substance abuse issues all over the UK because of the way this has been organised and
structured is both radical and feels very much in the spirit of the relational work that we are
doing as child and adolescent counsellors.
Schindler and Broning concluded that ‘to our knowledge, no attachment-oriented preventive
programme for at-risk adolescents exists to date’ (2012) and this would be an area for future
18
development opportunities. Another study that was published very recently gave ideas for
future research avenues also. It was looking at the relational pathways to substance misuse
– the role of trauma, insecure attachment and shame. Brene Brown has done a great deal
of research into shame, shame resilience and the correlation between shame and addiction
(Brown, 2006) so further study would be insightful as for me guilt and shame were drivers for
my addiction and my felt sense is that these buried emotions were also a hangover from
childhood experiences.
There were limitations to the area of research as indicated by the use of the self-reporting
TAS-20 tool to assess alexithymia that required some level of emotional insight and the
ongoing debate about whether the attachment observation was recording a relational state
or a personality trait.
Conclusion:
Oskis et al (2013) conclusion that ‘the presence of felt attachment and emotional and social
support may act as buffer to developing an externally orientated cognitive style’ offers insight
that if that experience could be role-modelled with a counsellor or specialist service team
members during adolescence this may allow repair and integration and help mediate
alexithymia. So both Schindler and Broning from an attachment and addiction standpoint
and Oskis from an alexithymia and addiction standpoint concurred on the therapeutic value
of secure attachment role-modelling through a counselling relationship. Bevington et al have
then developed this further linking theory with clinical practice with the implementation of
AMBIT within Cambridgeshire CASUS.
Fletcher et al (2015) argues that attachment-focused therapy for addiction treatment remains
rare and that while altering an individual’s attachment style may involve longer-term
treatment, longitudinal studies of current short-term substance abuse treatments suggest
longer-term treatment may be necessary. Additionally, they argue that the costs associated
with ‘healing attachment wounding may well be outweighed by the sustained, global benefits
experienced by individuals, their loved ones and shared communities’. I would support this
view and argue that investment in CAMHS, and particularly in CASUS, is a vital area of
support required within the UK.
There were only four research papers (Oskis et al, 2013; Schindler and Broning, 2014 and
Bevington et al, 2012 & 2015) that looked specifically at the issue of attachment and
addiction or alexithymia and addiction in adolescents as discussed. This is definitely an
under-studied area and the need for further research was supported by an email
conversation between Professor Thorberg and myself during the research phase of this
19
assignment where I approached him regarding research pointers into the chosen subject
area to which he replied “While I was working for the Centre for Youth Substance Abuse
Research at UQ (University of Queensland, Brisbane, Australia) quite a few years back I
was looking into this myself thinking about writing a review paper on the subject. However,
like you I did not find much. I talked to a colleague of mine last year from Yale that was
looking into this area as well and she did not find much either. As such, this is really an
‘open research area’ with very little having been done.”
What the four most pertinent research papers have supported and allowed me to tentatively
explore is my initial hypothesis and wondering that if a young person experiences restorative
relational therapy where secure attachment is role-modelled as an adolescent and is able to
work on and overcome alexithymic states and traits would the addiction have been stopped
from developing or reduced in severity? Their findings support this hypothesis but it must
be acknowledged that further outcome research results are needed, although the preliminary
results from Cambridgeshire CASUS are encouraging. As expressed by Bevington et al
(2012):
‘A real priority is now to gather more robust evaluative evidence of effectiveness. The
overarching goal is, of course, to divert desperate developmental and psychopathological
trajectories toward more adaptive pathways, with a view to reducing the frequency and
intensity of those outcomes that are most costly in terms of suffering and the financial
implications of later treatment options’.
Within this assignment I have explored and critiqued the literature around the three distinct
subjects of insecure attachment, affect regulation and alexithymia and addiction in
adolescence and how one may lead to and influence the other. Then I have explored the
psychotherapeutic treatment interventions currently available and looked at potential future
areas for research development and any study limitations. This literature review and
research study has informed and helped me greatly to learn more about this specific and
important, but definitely under researched, area of psychotherapeutic counselling need.
More importantly the discussions have indicated not only what further approaches may work
to support young people with substance misuse issues but what are already working and in
therapeutic use within CAMHS, and specifically CASUS, here in Cambridgeshire. It would
be valuable for child and adolescent counsellors to have training in the skills used with
AMBIT to support and complement other integrative approaches already being used as initial
research into what the link between insecure attachment, alexithymia and addiction in
adolescents suggests that the lack of positive attachment experiences, and the associated
20
emotional and social support, is the link and that providing a relational approach where a
role-modelled secure attachment is experienced is a psychotherapeutically beneficial
treatment approach.
7760 words
21
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