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Attachment style among outpatients with substance use disorders in psychological treatment
Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Region Östergötland, Local Health Care Services in East Östergötland, Department of Dependency in Norrköping.
Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
2018 (English)In: Psychology and Psychotherapy: Theory, Research and Practice, ISSN 1476-0835, E-ISSN 2044-8341, Vol. 91, no 4, p. 490-508Article in journal (Refereed) Published
Abstract [en]

Objectives

To explore the associations between self-rated attachment style, psychological distress and substance use among substance use disorder (SUD) outpatients in psychological treatment.

Design and Methods

In this practice-based study, 108 outpatients were asked to fill in the Experiences in Close Relationships – Short form, the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM), the Alcohol Use Disorders Identification Test (AUDIT), and the Drug Use Disorders Identification Test (DUDIT) at treatment start and end. Patients were given psychological treatments with a directive, reflective or supportive orientation.

Results

An insecure attachment style was more common among the SUD outpatients, compared to non-clinical groups. Patients with a fearful attachment style scored higher on psychological distress than patients with a secure attachment style. The associations between the attachment dimensions and psychological distress were stronger than those between attachment and SUD. Significantly more patients had a secure attachment style at treatment end.

Conclusions

This study shows significant relations between patients’ attachment style and their initial psychological distress. The causal relationship between attachment style and psychological distress is, however, not clear and can likely go in both directions. The psychological treatment of patients with SUD contributed significantly to changes from insecure to secure attachment style.

Practitioner Points

We found among patients with SUD a strong relation between patients’ attachment style and their psychological distress. Knowledge of the patient’s attachment style may help the therapist to tailor the treatment to the patient’s needs. A change from insecure to secure attachment style can be an important goal for a SUD treatment, as it may prevent the patient from using defence strategies involving substance use for regulating emotions and interpersonal relationships.

Place, publisher, year, edition, pages
John Wiley & Sons, 2018. Vol. 91, no 4, p. 490-508
Keywords [en]
attachment, CORE-OM, ECR-S, practice-based study, psychological distress, substance use disorder
National Category
Psychology
Identifiers
URN: urn:nbn:se:liu:diva-152442DOI: 10.1111/papt.12172ISI: 000451783900004OAI: oai:DiVA.org:liu-152442DiVA, id: diva2:1259846
Note

Funding agencies: Region Council in Ostergotland, Sweden [LIO-279451]; Department of Dependency Disorders, Vrinnevi Hospital, Norrkoping, Sweden

Available from: 2018-10-31 Created: 2018-10-31 Last updated: 2018-12-20Bibliographically approved
In thesis
1. Psychological treatment of outpatients with substance use disorders in routine care: attachment style, alliance, and treatment outcome
Open this publication in new window or tab >>Psychological treatment of outpatients with substance use disorders in routine care: attachment style, alliance, and treatment outcome
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Substance use disorder is one of the most important threats to health and welfare in the world. More knowledge is needed about the outcomes of treatments in routine care for patients with substance use disorders (SUDs). These patients often suffer from psychological distress in addition to substance use disorders.

Aims: To evaluate the effects of community-based psychological treatment on SUD outpatients’ psychological distress and substance use, and also to analyze the importance of their attachment style and the alliance with regard to treatment outcome.

Methods: Patients who were referred or self-referred to a social worker or a psychotherapist at three outpatient treatment centers for SUD were invited to participate in the study. At each session the patients filled out an instrument measuring psychological distress, the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM) and to evaluate the alliance to the therapist the Working Alliance Inventory – short form revised (WAI-SR). At treatment start and end the patient filled out the Alcohol Use Disorders Identification Test (AUDIT), the Drug Use Disorders Identification Test including the extended version (DUDIT/DUDIT-E) and the Experiences in Close Relationships – short form (ECR-S) categorizing attachment style. Therapists filled out the CORE Therapy Assessment form at treatment start and the End of Therapy form at treatment termination. After each session, they also filled out the Working Alliance Inventory – short form for therapists (WAI-S).

Results: Of the 119 patients who agreed to participate in the study, there were 100 patients who filled out two or more CORE-OM and WAI-SR forms. Outcome on substance use as measured with AUDIT-C and DUDIT-C was collected for 63 patients. The analyses showed that CORE-OM mean scores were significantly improved. In total 14% of the patients were recovered, 10% improved and 5% deteriorated. AUDIT-C and DUDIT-C mean scores were significantly improved for patients using alcohol and for patients using illicit drugs, respectively.

An insecure attachment style was more common among the patients in this research project, compared to non-clinical groups. The patients with a fearful attachment style scored higher on psychological distress than the patients with a secure attachment style. The associations between the attachment dimensions and psychological distress were stronger than those between attachment and SUD. The causal relationship between attachment style and psychological distress is, however, not clear and can likely go in both directions. Significantly more patients had a secure attachment style at treatment end.

Previous studies have found that the associations between alliance and outcome for SUD patients may be weaker than for other clinical groups, which was confirmed in this thesis. Three moderators of the alliance-outcome association – type of substance use, attachment style and treatment orientation – were assessed. None of the potential moderators tested showed any effect on the association between alliance and psychological distress. The variance among the therapies concerning the session-to-session alliance-outcome association was considerable, indicating that other moderating variables might be found.

Conclusions: Routine psychological treatment had positive effects on psychological distress as well as on reduction of substance use. However, a substantial number of patients remained unchanged, particularly regarding psychological distress. Among patients with SUD there seems to be a strong relationship between attachment style and psychological distress. Knowledge of the patient’s attachment style may help the therapist to tailor the treatment to the patient’s needs. A change from an insecure to a secure attachment style can be an important goal for SUD treatment, as it may prevent the patient from using strategies involving substance use for regulating emotions and interpersonal relationships. This thesis confirms and strengthens the finding of a weaker association between alliance and outcome for SUD patients, compared to other clinical groups. A challenge for further research is to find factors that contribute to the alliance-outcome association among SUD patients.

Studies with larger patient groups, additional instruments and methods are needed to develop treatments for SUD patients in routine care.

Abstract [sv]

Substansbrukssyndrom utgör ett av de allvarligaste hoten mot hälsa och välstånd i världen. Det behövs mer kunskap om effekterna av de behandlingar som erbjuds patienter med substansbrukssyndrom i den kliniska vardagen. Dessa patienter lider ofta av psykologiska besvär, utöver själva substansbrukssyndromet.

Målsättningen med denna avhandling har varit att utvärdera effekterna av psykologisk behandling för patienter med substansbrukssyndrom i öppenvård avseende psykologiska problem och substansbruk, samt att analysera betydelsen av patienternas anknytningsstil och alliansen mellan patient och behandlare.

Till studien inbjöds patienter som remitterats eller själva sökt psykologisk behandling hos en socialarbetare eller psykoterapeut vid tre öppenvårdsmottagningar för substansbrukssyndrom. De patienter som accepterade att delta fick vid varje behandlingstillfälle fylla i ett formulär som mäter psykologiska besvär, CORE-OM, samt WAI-SR, som mäter den allians som patienten upplever med sin behandlare. Vid första och sista behandlingstillfället fick patienten också fylla i AUDIT-formuläret som mäter problem relaterade till alkohol, DUDIT-formuläret som mäter problem relaterade till användning av droger samt ECR-S-formuläret som mäter erfarenheten av en aktuell nära relation, vilken kan klassificeras som anknytningsstil. Terapeuten fyllde vid behandlingens början i CORE bedömningsformulär samt efter sista behandlingstillfället det avslutningsformulär som också ingår i CORE. Terapeuten fyllde vid varje behandlingstillfälle i sin egen skattning av alliansen med patienten (WAI-S).

Av det totalt 119 patienter som accepterade att delta i studien, fyllde 100 patienter i minst två CORE-OM- och WAI-SR-formulär, vilket möjliggjorde en mätning av den förändring som behandlingen medfört avseende psykologiska besvär. Vad gäller effekter på substansbruket kunde detta göras för 63 patienter som fyllt i AUDIT-C och DUDIT-C vid både start och slut av behandlingen, frågor om aktuellt substansbruk. Vad gäller psykologiska besvär visade studien efter sista behandlingstillfället en signifikant förbättring av CORE-OM-poängen, med total 14% av patienterna botade och 10% reliabelt förbättrade. En reliabel försämring konstaterades för 5% av patienterna. Medelvärdet av både alkoholkonsumtion och bruk av droger minskade signifikant och med stark effekt vid behandlingens slut.

En otrygg anknytningsstil var mer vanlig hos patienterna i studien jämfört med ickekliniska grupper. De patienter som i självskattningsformuläret uppvisade en desorganiserad anknytningsstil hade också högre poäng vad gäller psykologiska besvär, jämfört med de som vid behandlingsstart hade en trygg anknytningsstil. Sambandet mellan anknytningsstil och psykologiska besvär var också starkare än det mellan anknytningsstil och substansbrukssyndrom. Orsakssambandet mellan anknytningsstil och psykologiska besvär är dock inte utrett och kan troligen gå i båda riktningarna. Signifikant fler patienter hade vid behandlingens slut en trygg anknytningsstil.

Tidigare studier har funnit att i terapier med substansbrukssyndrom är sambandet mellan allians och behandlingsutfall svagare jämfört med andra kliniska grupper, vilket bekräftades i den här avhandlingen. Tre moderatorer – typ av substansbruk, anknytningsstil och behandlingsinriktning – utvärderades avseende deras påverkan på relationen mellan allians och behandlingsutfall. Ingen av de potentiella moderatorerna uppvisade någon effekt på relationen mellan allians och utfall avseende psykologiska besvär. Dock fanns det betydande skillnader mellan olika patienter när det gällde sambandet mellan allians och utfall från en session till nästa, något som indikerar att andra moderatorer av betydelse skulle kunna finnas.

Sammanfattningsvis visade studien att psykologisk behandling i den kliniska vardagen av patienter med substansbrukssyndrom gav positiva effekter både på psykologiska besvär och på substansbruk. En avsevärd del av patienterna var emellertid oförändrade, framförallt avseende psykologiska besvär. För patienter med substansbrukssyndrom verkar det finnas en stark relation mellan anknytningsstil och psykologiska besvär. Kunskap om patientens anknytningsstil kan hjälpa terapeuten att utforma en behandling utifrån patientens behov. En förändring från otrygg till trygg anknytningsstil kan vara ett viktigt mål för behandling av substansbrukssyndrom, då det kan få patienten att avstå från strategier där substansbruk används för att hantera känslomässig stress, reglera affekter och interpersonella relationer. Studien bekräftar och stärker också slutsatsen att sambandet mellan allians och behandlingsutfall är svagare för patienter med substansbrukssyndrom jämfört med andra patientgrupper. En utmaning för framtida studier är att identifiera faktorer som bidrar till relationen mellan allians och behandlingsutfall för patienter med substansbrukssyndrom.

Studier med större patientgrupper, fler mätinstrument och metoder är nödvändiga för att utveckla behandlingar i den kliniska vardagen för patienter med substansbrukssyndrom.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2018. p. 62
Series
Linköping Studies in Arts and Sciences, ISSN 0282-9800 ; 755Linköping Studies in Behavioural Science, ISSN 1654-2029 ; 212
National Category
Psychology
Identifiers
urn:nbn:se:liu:diva-152443 (URN)10.3384/diss.diva-152443 (DOI)9789176851975 (ISBN)
Public defence
2018-11-23, I:101, Hus I, Campus Valla, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2018-10-31 Created: 2018-10-31 Last updated: 2019-09-26Bibliographically approved

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Gidhagen, YlvaHolmqvist, RolfPhilips, Björn

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