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Attachment Style and Treatment Completion among Psychiatric Inpatients with Substance Use Disorders

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James Christopher Fowler at Baylor College of Medicine
James Christopher Fowler
Michael Groat at Silver Hill Hospital
Michael Groat
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Mike Ulanday
Mike Ulanday
Mike Ulanday
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Abstract and Figures

A strong dose-response relationship exists for psychosocial treatments for co-morbid substance abuse disorders; yet rates of attrition are exceedingly high for those seeking treatment in residential and hospital settings. This study examined patient characteristics, including attachment style as predictors of completing 42 contiguous days of inpatient dual-diagnosis treatment among patients with substance use disorders. Baseline characteristics were assessed in 187 consecutively admitted patients with research diagnosis of substance use disorders. Hierarchical logistic regression analysis was used to examine predictors of treatment retention. Results indicated a two-variable model consisting of total number of co-occurring Axis I and II disorders, and pre-occupied attachment style, accounting for 17% of the variance. Attachment status predicted retention above and beyond psychiatric co-morbid disorders, demonstrating incremental predictive validity. Moderator analyses failed to detect an interaction. Among inpatients with substance abuse disorders, anxious-preoccupied attachment style predicted treatment retention, reflecting the importance of interpersonal components of treatment relationships in completing treatment. This study adds to a growing body of evidence linking attachment style with treatment adherence. Further research is needed to examine possible mechanisms associated with this relationship. (Am J Addict 2013;22:14-17).
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Attachment Style and Treatment Completion among
Psychiatric Inpatients with Substance Use Disorders
James Christopher Fowler, PhD, Michael Groat, PhD, Mike Ulanday, BA
Department of Psychiatry, Menninger Clinic Baylor College of Medicine, Houston, Texas
Background and Objectives: A strong dose–response relationship
exists for psychosocial treatments for co‐morbid substance abuse
disorders; yet rates of attrition are exceedingly high for those seeking
treatment in residential and hospital settings. This study examined
patient characteristics, including attachment style as predictors of
completing 42 contiguous days of inpatient dual‐diagnosis treatment
among patients with substance use disorders.
Methods: Baseline characteristics were assessed in 187 consecutively
admitted patients with research diagnosis of substance use disorders.
Hierarchical logistic regression analysis was used to examine
predictors of treatment retention.
Results: Results indicated a two‐variable model consisting of total
number of co‐occurring Axis I and II disorders, and pre‐occupied
attachment style, accounting for 17% of the variance. Attachment
status predicted retention above and beyond psychiatric co‐morbid
disorders, demonstrating incremental predictive validity. Moderator
analyses failed to detect an interaction.
Conclusions and Scientific Significance: Among inpatients with
substance abuse disorders, anxious‐preoccupied attachment style
predicted treatment retention, reflecting the importance of interper-
sonal components of treatment relationships in completing treatment.
This study adds to a growing body of evidence linking attachment
style with treatment adherence. Further research is needed to examine
possible mechanisms associated with this relationship. (Am J Addict
2013;22:14–17)
INTRODUCTION
Early termination from psychiatric and substance abuse
treatment contributes to limited benefit and reduced cost
effectiveness of psychiatric services.
1
Attrition rates are
comparable across medical, psychiatric, and substance abuse
treatment programs, yet for individuals entering substance
abuse programs, those terminating prematurely face similar
outcomes as those never entering treatment.
2
In contrast,
longer treatment duration is the most consistent predictor of
positive treatment outcomes among substance use disorders.
3,4
Identifying predictors of treatment retention is particularly
important in light of evidence that a large percentage of
individuals entering drug and alcohol treatment fail to
complete prescribed treatment protocols, especially those
enrolled in long‐term residential programs.
5
Empirical research examining psychiatric disturbance as a
predictor of early termination produce puzzling results—co‐
occurring psychiatric disorders negatively impacting treatment
retention and completion;
6–8
yet, higher psychiatric co‐
morbidity and severity of symptoms also predict retention.
9,10
To date it remains unclear which factors predict treatment
retention among inpatients with substance use disorders, but a
recent multinational study of outpatient substance abuse
treatment indicate the need for multidimensional assessment
of patient factors including employment status, polysubstance
use, and burden of psychiatric co‐morbidity.
11
In addition,
early adverse events and personality characteristics go
undetected in most studies, yet may influence retention via
the capacity to develop collaborative treatment alliance.
Distal factors such as gender, age, and socioeconomic status
are minimally predictive of treatment retention; however, few
studies examine proximal characteristics that may influence
individual choice to complete a prescribed course of inpatient
treatment. Patients who struggle to collaborate with treatment
providers frequently have a long‐standing pattern of poor
treatment adherence, suggesting the influence of underlying
stable characteristics. If there are measurable patient character-
istics that predict treatment completion among high‐drop out
cohorts such as inpatients with co‐occurring substance use
disorders, this information may be useful in shaping treatment
approaches and recommendations in similar clinical settings.
Attachment style is a likely candidate phenotype for impair-
ments in forming and maintaining productive therapeutic
contacts. Among diabetic patients, attachment insecurity is
linked to greater interpersonal distance, dissatisfaction, and
difficulty forming collaborative relationships with healthcare
providers,
12
poorer medication compliance,
13
and ultimately
higher mortality rates.
14
The current study examined predictors
of completing 42 contiguous days of inpatient dual‐diagnosis
Received November 7, 2011; revised November 25, 2011;
accepted December 1, 2011.
Address correspondence to Dr. Fowler, Department of Psychiatry,
Menninger Clinic Baylor College of Medicine, 12301 Main St.,
Houston, TX 77035. E‐mail: cfowler@menninger.edu.
The American Journal on Addictions, 22: 14–17, 2013
Copyright © American Academy of Addiction Psychiatry
ISSN: 1055-0496 print / 1521-0391 online
DOI: 10.1111/j.1521-0391.2013.00318.x
14
treatment among patients with substance use disorders. This
specialized program is optimized for 42 days of treatment (or
greater) in order to optimize medication education and therapy,
complete a full cycle of individual and group programming
including addictions counseling education and recovery,
cognitive behavioral therapy (CBT), dialectical behavioral
therapy (DBT) skill‐building, mentalizing education and
therapy, family education and therapy, group psychotherapy,
neuroscience education, trauma assessment, and 12‐step
program participation. Discharge follow‐up care is dependent
on assessment of individual patient needs and resources.
METHODS
Participants were 187 individuals who met research criteria
for Axis I substance use disorder that were consecutively
admitted to a specialized psychiatric hospital with a dual
diagnosis track between October 2010 and August 2011.
Gender distribution was comparable: 98 were women (52.5%)
and 89 were men (47.5%). Age ranged from 18 to 66,
averaging 30.8 years (SD ¼12.1). Most participants reported
being unemployed or working less than 10 hours per week in
the month prior to admission (n¼119, 65.3%), single‐never
married (n¼120, 65.6%) or currently married (n¼30,
16.4%). Participants were Caucasian (n¼161, 88%), multi-
racial (n¼12, 6.6%), and Asian (n¼5, 2.2%). Six subjects
(3.3%) identified as being of Hispanic or Latino ethnicity.
Participants were assessed at admission via hospital‐wide
survey as part of a combined quality improvement and research
initiative; thus all patients consented to participation and
no patients declined as it was integrated into clinical care.
Use of data was approved by Baylor College of Medicine’s
Institutional Review Board.
Demographic data including age, gender, recent employ-
ment, disability status, history of trauma, and treatment history
(number of prior hospitalizations and history of attrition from
outpatient and inpatient treatment), were collected by self‐
report at baseline. Psychiatric diagnoses were assessed
using the structured clinical interview for DSM‐IV Axis I
disorders, and structured clinical interview for DSM‐IVAxis II
personality disorders. Depressive severity was assessed
using the Beck Depression Inventory‐II. Attachment style
was assessed with the brief self‐report relationship question-
naire (RQ)
15
in which respondents are provided with
prototypical descriptions of secure, dismissing, preoccupied,
and fearful attachment patterns, then asked to rate on a
seven‐point scale the extent to which each description
corresponds to their general relationship style. The RQ has
adequate psychometric properties, and demonstrated construct
and predictive validity.
12–14
Inventory of interpersonal prob-
lems
16
is a 32‐item self‐report measure of interpersonal
problem domains including: domineering/controlling, vindic-
tive/self‐centered, cold/distant, socially inhibited, nonasser-
tive, overly accommodating, self‐sacrificing, and intrusive/
needy.
Analysis
Analyses were conducted using SPSS for windows, version
19.1. Step‐wise hierarchical logistic regression analyses were
utilized to estimate relative and incremental contribution of
patient factors in predicting treatment retention of 42 days or
more. Significance level was set at p< .05 for all analyses and
moderator analyses were conducted to test for interactions.
RESULTS
Fifty‐five (29%) inpatients with co‐occurring substance use
disorders discontinued treatment before the prescribed 42‐day
protocol with 132 (71%) completing 42 days or more. Results
(Table 1) indicate a final regression model with a two variable
solution accounting for approximately 17% of the estimated
variance. Number of co‐occurring Axis I/II disorders entered
in Step 3 with higher number of co‐occurring disorders
associated with treatment retention (B¼.32, Wald ¼10.64,
Naegelkerke R
2
¼.09, p<.001). Preoccupied attachment
style entered the model at Step 5, adding approximately 8% of
the variance to the prediction (B¼1.33, Wald ¼10.38,
Naegelkerke R
2
¼.17, p<.001), thus demonstrating incre-
mental validity over and above psychiatric co‐morbidity.
Effect sizes were computed because Naegelkerke R
2
can be an unstable estimate of effect size: number of co‐
occurring DSM diagnoses produced a medium effect (Cohen’s
d¼.56) and preoccupied attachment style produced a
medium effect (Cohen’sd¼.56). Moderator analyses were
nonsignificant.
DISCUSSION
Psychological dimensions most relevant to the development
and maintenance of collaborative treatment relationships are
rarely included in studies of treatment retention among substance
users. Rare exceptions include the role of psychological distress
tolerance in residential substance abuse treatment dropout,
17
and
high levels of interpersonal dependency related to outpatient
substance abuse treatment completion.
18
Baseline factors such as age, gender, type, and total number
of substances abused, trauma and recent work and disability
history did not predict treatment completion. History of
multiple hospitalizations and prior history of unilaterally
terminating treatment relationships also failed to predict
completion. This is the first study to demonstrate that
attachment style predicts treatment continuation over and
above diagnostic co‐morbidity.
The RQ anxious‐preoccupied prototype reflects psycholog-
ical discomfort in the absence of a close attachment, and a
strong desire to be emotionally intimate with others beyond
what is comfortable for others. While this attachment style is
characterized in dyadic relationships, the current findings
indicate that anxious‐preoccupied attachment strategy may
operate on a broader social level, similar to interpersonal
Fowler, Groat, and Ulanday January–February 2013 15
dependency that has been shown to influence help‐seeking
behaviors across an inpatient institution,
19
as well as influence
completion of a substance abuse treatment protocol.
18
Strengths of the current study include a prospective design,
ecologically valid definition of treatment completion, the use
of predictors from multiple domains, and a data analytic
strategy assessing unique and incremental validity of pre-
dictors. While the results are promising, modest sample size
and the relative lack of racial, ethnic, and socioeconomic
diversity limits the generalizability of the current findings.
CONCLUSIONS
Greater co‐morbidity among patients with substance use
disorders has been associated with greater attrition rates in
several large scale studies; yet this study found the opposite.
One explanation for the counterintuitive finding is the program
focus on co‐occurring disorders and attention to cognitive and
affective dimensions of psychopathology that increase risk of
relapse. This focus, combined with attention to personality
characteristics and enhancing therapeutic alliance may be
partially responsible for the greater retention among the most
impaired patients. While anxious‐preoccupied attachment
style was predictive of retention, other insecure attachment
styles (fearful, dismissive) were not predictive of retention or
attrition—it is unclear if these attachment organizations are
predictive of retention in more traditional substance abuse
treatment programs. The small sample and lack of process data
limit speculations regarding mechanisms of retention. These
preliminary results contribute to a growing body of evidence
indicating that psychological factors should be included in
studies of substance abuse attrition and retention.
This research was supported by funding from the
Menninger Foundation and the McNair Medical Institute,
Houston, TX.
Declaration of Interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this paper.
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TABLE 1. Hierarchical logistic regression of treatment completion status
Predictor BModel x
2
p‐Value Nagelkerke R
2
Constant
Step 1 Demographics
Step 2 Personal history
Step 3 DSM‐IV co‐morbid .38 12.0 .001 .09
Step 4 BDI‐II
Step 5 Attachment status 1.3 12.2 .000 .17
Step 6 Interpersonal problems
Step 1: age, gender.
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Step 3: total number of Axis I and Axis II disorders.
Step 4: Beck Depression Inventory‐II Total Score.
Step 5 RQ: attachment styles: secure, preoccupied, fearful, and dismissive.
Step 6 IIP‐32: domineering/controlling, vindictive/self‐centered, cold/distant, socially inhibited, nonassertive, overly accommodating, self‐sacrificing, and
intrusive/needy.
16 Attachment Style and Treatment Completion January–February 2013
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  • Feb 2011
  • EUR ADDICT RES
Policies and practices related to the quasi-compulsory treatment (QCT) of substance-dependent offenders are currently implemented in many countries, despite the absence of reliable knowledge about significant predictors of treatment retention. This study aimed to identify such predictors in QCT and voluntary treatment. Participants were treated in one of 65 institutions in 5 European countries. They were interviewed at intake on substance use, crimes committed, perceived pressure for treatment, self-efficacy, stage of change, employment, and health-related variables. Binary logistic regression models were computed to identify predictors of treatment retention at an 18-month follow-up. Moderator analyses were computed to investigate whether these predictors vary by treatment condition (QCT vs. voluntary). A higher number of working days in the previous month was positively associated with treatment retention, while use of heroin, crack, and multiple drugs, psychiatric problems in the previous month, and lifetime depression were negatively associated with treatment retention. Higher perceived medical pressure resulted in higher treatment retention rates only for participants in QCT. Predictors of substance abuse treatment retention are quite similar across both QCT and voluntary treatments. Perceived medical pressure is of higher relevance than the often-believed legal pressure for treatment retention in QCT.
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Relationship Styles and Mortality in Patients With Diabetes
Article
Full-text available
  • Dec 2009
OBJECTIVE Prior research has shown that less social support is associated with increased mortality in individuals with chronic illnesses. We set out to determine whether lower propensity to seek support as indicated by relationship style, based on attachment theory, is associated with mortality in patients with diabetes. RESEARCH DESIGN AND METHODS A total of 3,535 nondepressed adult patients with type 1 and type 2 diabetes enrolled in a health maintenance organization in Washington State were surveyed at baseline and followed for 5 years. Relationship style was assessed at baseline. Patients with a greater propensity to seek support were classified as having an interactive relationship style and those less inclined to seek support as having an independent relationship style. We collected Washington State mortality data and used Cox proportional hazards models to estimate relative risk (RR) of death for relationship style groups. RESULTS The rate of death in the independent and interactive relationship style groups was 39 and 29 per 1,000 individuals, respectively. Unadjusted RR of death was 1.33 (95% CI 1.12–1.58), indicating an increased risk of death among individuals with an independent relationship style. After adjustment for demographic and clinical covariates, those with an independent relationship style still had a greater risk of death compared with those with an interactive relationship style (hazard ratio 1.20 [95% CI 1.01–1.43]). CONCLUSIONS In a large sample of adult patients with diabetes, a lower propensity to reach out to others is associated with higher mortality over 5 years. Further research is needed to examine possible mechanisms for this relationship and to develop appropriate interventions.
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Predicting Response to Alcohol and Drug Abuse Treatments
Article
  • Jun 1983
  • ARCH GEN PSYCHIAT
• Male alcoholics (n=460) and drug addicts (n=282) were evaluated at six-month follow-up after treatment in six rehabilitation programs. Initial analyses of the unstratified samples showed significant patient improvement, but no evidence of differential effectiveness from different treatments or from "matching" patients to treatments. The two samples were then divided into groups based on the number, duration, and intensity of their psychiatric symptoms at admission, ie, their overall "psychiatric severity." Patients with low psychiatric severity improved in every treatment program. Patients with high psychiatric severity showed virtually no improvement in any treatment. Patients with midrange psychiatric severity (60% of the samples) showed outcome differences from different treatments and especially from specific patient-program matches. These findings support the effectiveness and specificity of different substance abuse treatments, suggest methodologic reasons for the lack of similar findings in previous studies, and demonstrate the importance of psychiatric factors in substance abuse treatment.(Arch Gen Psychiatry 1983;40:620-625)
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Dropping out of Substance Abuse Treatment: A Clinically Oriented Review
Article
  • Dec 1992
  • CLIN PSYCHOL REV
Early attrition from substance abuse treatment is very high, although rates do not differ dramatically from those found in medical and psychiatric treatments. The consequences of substance abuse treatment dropout are severe, however, with early dropouts having the same outcome as untreated clients. Evidence is considered regarding the impact of demographic and social variables on continuation in treatment. The effects of client motivation, substance use, criminality and legal pressure, prior treatment history, and psychopathology are also examined. An analysis of treatment factors and procedures used to enhance retention indicates that more conveniently located, smaller, decentralized clinics, with higher clinical staff ratios and more per capita expenditures, have lower attrition rates. Clients are also likely to continue in treatment longer when they receive rapid initial response and individual attention, and when they are seen in smaller groups in friendly, comfortable environments. Inexpensive techniques such as reminder phone calls and personal letters can be employed in the absence of resources needed to mount more extensive attrition prevention interventions.
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Early memories, object relations, and current relationship functioning
Article
  • Sep 2011
This study examined the relationship between dependency themes in 140 inpatients' early childhood memories (EM) and social interactions involving dependent behavior. Hierarchical regression analyses revealed that the type of dependent EM predicted overt behavior above and beyond demographic and diagnostic categories. Patients expressing clinging dependent themes in their narratives had greater involvement in social activities in the therapeutic community program and with nurses, whereas patients expressing counterdependent themes engaged in more hostile interactions with nursing staff members, were more self-destructive, and had more emergency department admissions over the course of inpatient treatment. Results are considered in light of the clinical utility of EMs.
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Client and Program Factors Associated with Dropout from Court Mandated Drug Treatment
Article
  • Aug 2009
To examine why court mandated offenders dropout of drug treatment and to compare their characteristics, treatment experiences, perceptions, and outcomes with treatment completers, we analyzed self-reported and administrative data on 542 dropouts (59%) and 384 completers (41%) assessed for Proposition 36 treatment by thirty sites in five California counties during 2004. At intake, dropouts had lengthier criminal histories, lower treatment motivation, more severe employment and psychiatric problems, and more were using drugs, especially heroin. Relatively fewer dropouts received residential treatment and their retention was much shorter. A similar proportion of dropouts received services as completers and the mean number of services received per day by dropouts was generally more, especially to address psychiatric problems, during the first three months of treatment. The most commonly offender-reported reasons for dropout included low treatment motivation (46.2%) and the difficulty of the Proposition 36 program (20.0%). Consequences for dropout included incarceration (25.3%) and permission to try treatment again (24.0%). Several factors predicting drug treatment dropout were identified. Both groups demonstrated improved functioning at one-year follow-up, but fewer dropouts had a successful outcome (34.5% vs. 59.1%) and their recidivism rate was significantly higher (62.9% vs. 28.9%) even after controlling for baseline differences. Understanding factors associated with drug treatment dropout can aid efforts to improve completion rates, outcomes, and overall effectiveness of California's Proposition 36 program. Findings may also aid a broader audience of researchers and policy analysts who are charged with designing and evaluating criminal-justice diversion programs for treating drug-addicted offenders.
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Patient Factors Related to Early Attrition from an Outpatient Cocaine Research Clinic: A Preliminary Report
Article
  • Apr 1991
  • Int J Addict
Of 60 cocaine misusers seeking outpatient treatment, 33 (55%) dropped out by 4 weeks. Dropouts were more likely to be male, Black or Hispanic, or with no history of primary depression. Completers were more likely to be White, female, or depressed. The implications of these findings and possible strategies for reducing the dropout rate are discussed.
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Attachment Styles Among Young Adults: A Test of a Four-Category Model
Article
  • Sep 1991
A new 4-group model of attachment styles in adulthood is proposed. Four prototypic attachment patterns are defined using combinations of a person's self-image (positive or negative) and image of others (positive or negative). In Study 1, an interview was developed to yield continuous and categorical ratings of the 4 attachment styles. Intercorrelations of the attachment ratings were consistent with the proposed model. Attachment ratings were validated by self-report measures of self-concept and interpersonal functioning. Each style was associated with a distinct profile of interpersonal problems, according to both self- and friend-reports. In Study 2, attachment styles within the family of origin and with peers were assessed independently. Results of Study 1 were replicated. The proposed model was shown to be applicable to representations of family relations; Ss' attachment styles with peers were correlated with family attachment ratings.
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Personality disorders and alcohol treatment outcome
Article
  • Aug 1988
  • DRUG ALCOHOL DEPEN
The relationship existing between personality disorders (classified according to DSM III) and alcohol treatment outcome was evaluated in 404 alcoholics admitted to the Psychiatric Clinic of the University of Trieste, Italy. One quarter of the subjects had personality disorders, mainly of the 'antisocial', 'dependent', and 'borderline' subtypes. Alcohol abuse was specifically related to 'antisocial' personalities. Marked differences in treatment outcome among personality disorders were found. Group therapy for alcoholism was not beneficial to 'antisocial' personalities; it was most useful among 'dependent' subjects.
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Predicting Response to Alcohol and Drug Abuse Treatments: Role of Psychiatric Severity
Article
  • Jul 1983
  • ARCH GEN PSYCHIAT
Male alcoholics (n = 460) and drug addicts (n = 282) were evaluated at six-month follow-up after treatment in six rehabilitation programs. Initial analyses of the unstratified samples showed significant patient improvement, but no evidence of differential effectiveness from different treatments or from "matching" patients to treatments. The two samples were then divided into groups based on the number, duration, and intensity of their psychiatric symptoms at admission, ie, their overall "psychiatric severity." Patients with low psychiatric severity improved in every treatment program. Patients with high psychiatric severity showed virtually no improvement in any treatment. Patients with midrange psychiatric severity (60% of the samples) showed outcome differences from different treatments and especially from specific patient-program matches. These findings support the effectiveness and specificity of different substance abuse treatments, suggest methodologic reasons for the lack of similar findings in previous studies, and demonstrate the importance of psychiatric factors in substance abuse treatment.
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