Attachment-Based Addiction Treatment (ABAT)
Theory and Model
©2021, Mary Crocker Cook
The Attachment-Based Addiction Treatment model is based on a simple proposal: individuals develop a secure attachment to substances to self-soothe in the absence of available caretakers.
Early attachment disruption interferes with a substance abusers’ ability to utilize relationships as recovery support. Poor emotional regulation and reflexive functioning skills result in an inability to implement the relationship-based interventions offered in substance abuse treatment.
By the end of the treatment episode the:
Experience in Close Relationship (ECR) questionnaire is altered toward secure
Reflective Self-Functioning Questionnaire altered toward increased mentalizing and metacognitive skills
Social Provisions scale altered toward increase of use of others for guidance, reassurance of worth, social integration, attachment, nurturance, and reliable alliance
They will develop of a social map with demonstrated use of the ability to successfully include people in their recovery efforts.
While the use of substances is a reliable strategy that makes sense to the user, addiction hijacks the individual’s ability to form effective self-regulation skills and utilize support to achieve long-term sobriety. It is the foundation of this model that individuals who have experienced substantial attachment disruption are unable to utilize the traditional structure of addiction treatment and Twelve Step culture.
This population, with their accompanying trauma, require an approach that directly addresses this attachment disruption within the addiction treatment structure and staff. Recovering clients will need extensive assistance to gain self-regulation skills they can employ both individually and with others, and this includes strengthening their internal observer. They must develop the skills to accurately reflect on their own internal reality, and accurately reflect the reality of others.
A large part of their treatment will include an intentional development of a social network as part of relapse prevention planning, with frequent reflection on their own attachment style and how their currently attachment strategies may or may not be effective with the others in the treatment milieu as well as staff.
Attachment-Based Addiction Treatment is also a response to my professional quest, decades long, to create a clinical bridge between the mental health clinician culture and substance use counselor culture. As a professional that stands astride both specialties, I have often felt as though I had to speak from only one side of my professional experience based on the audience I might be addressing. The schism in cultures creates holes in our treatment planning, disharmony in treatment settings, and most importantly leads to disjointed and ineffective treatment for the isolated, suffering addict.
What links mental health and substance use cultures is early attachment theory and Edward Khantzian’s Self-Medication Hypothesis; his insight that addiction is pain relieving instead of pleasure seeking. The psychological pain, and eventually physical pain, is temporarily suspended by substances which means that he sees addiction as a self-regulation disorder. Often substance based self-regulation patterns were developed in response to a trauma-based attachment interruption, and all Attachment-Based Addiction Treatment needs to be offered in Trauma-informed settings. Trauma-informed systems and services take into account knowledge about trauma—its impact, interpersonal dynamics, and paths to recovery—and incorporate this knowledge thoroughly in all aspects of service delivery.
How Childhood Trauma Leads to Addiction - Gabor Maté (9:09)
In the process of these attempts to self-regulate with substances, the adaptation in brain circuitry and neurophysiology is altered in a way that the brain functioning of the substance abuser is permanently changed. Prolonged use of substances can alter neural synapses and the endogenous production of certain neurotransmitters that affect the reward center of the brain. In addition to the neurological changes of addiction, chronic stress leads to dysregulation of our stress hormones – which leads to unregulated inflammation. When we experience stressful emotions – anger, fear, worry, anxiety, rumination, grief, loss – the HPA axis releases stress hormones, including cortisol and inflammatory cytokines that promote inflammation. Inflammation translates into symptoms and disease that follows us well into adulthood. According to the “Theory of Everything” your emotional biography becomes your physical biology which is why there is a significant link between individuals who experience chronic stress and significantly higher levels of inflammation and disease.
The Attachment-Based Addiction Treatment model situates the physical and psychological pain in un-remediated attachment interruption, which traps recovering clients in a hyperarousal or hypo arousal neurological response resulting in an inability to self-soothe or receive soothing from external resources. In the process of attempting to manage attachment threats with substances clients are neurologically hijacked and develop the disease of addiction. Individuals who experience disorganized, avoidant, or anxious attachment in infancy develop difficulties in reflecting on their own thoughts and accurately reading the thoughts and intentions of others. This impaired ability prevents substance abusing clients from effectively identifying and interrupting their self-harming patterns. It also prevents them from fully utilizing the counseling, family and community support that research demonstrates are crucial for long-term recovery. This difficulty can lead to an increasingly discouraging relapse cycle.
Everything you think you know about addiction is wrong | Johann Hari
The Attachment-Based Addiction Treatment model provides a persuasive argument for the resulting emotional regulation possible when individuals understand what causes addiction (biochemistry and early attachment disruption), draw from interpersonal neurology to stabilize neurological flooding to address an overactive inflammatory system, identify attachment styles and attachment strategies, learn to recognize risk factors for relapse (cravings, environmental cues, and disruptive attachment strategies and defenses in relationships), and develop tools for coping with stressful situations (increasing ability to establish and maintain secure attachments to support metacognitive strategies and utilize recovery tools learned in treatment).