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Addiction (1993) 88, 1405-1411


Attachment among adult children of alcoholics


Foothills Hospital, Calgary, Alberta, Canada

Disturbed or impoverished relationships have been identified as a predominant feature of adult children of
alcoholics (ACOAs). Recently, the concept of co-dependency has been advanced to depict the interpersonal
difficulties of these individuals, but lacks definitional rigor. The notion that childhood experiences with parents
are 'carried forward' to affect attitudes and behaviors relevant to later intimate relationships is also consistent
with attachment theory. This study examined the pattems of attachment of ACOAs as compared to adult
children of non alcoholics (ACONAs). A cross-sectional sample of 203 individuals attending either a short
term hospital based outpatient psychiatric program or a community based alcoholism treatment program teas
included in this study. Results supported the hypothesis that female ACOAs had a distinctive dysfunctional
attachment profile. There were no significant differences in the attachment styles of male ACOAs as compared
to ACONAs, or male substance abusers as compared to non-abusers.

Introduction higher incidence of various fortns of emotional

Disturbed or impoverished relationships have problems, psychiatric disorders (Frances et al.,
been identified as a predominant feature of adult 1980; El-Guebaly et al., 1991) and in particular
children of alcoholics (ACOAs) (Penick et al., the higher incidence of substance abuse among
1978; Frances, Timm & Bucky, 1980; El-Gue- ACOAs (Nylander, I960; Rydelius, 1981;
baly et al., 1990). The co-dependency concept Schulsinger et al., 1986) as compared to the
has been advanced in the search for a way to adult children of non-alcoholics (ACONAs). Ad-
characterize and specify these interpersonal ditionally, there is a growing literature which is
problems. While receiving wide endorsement by critical of co-dependency as a potentially gender-
the general public, little theoretical or empirical biased construct (e.g. Asher & Brissett, 1988;
work has been done to elaborate and specify the Van Wormer, 1989; Wright & Wright, 1990).
precise nattire of co-dependency and its relation- Such critiques are based on the differential im-
ship to parental alcoholism (Morgan, 1991). portance of relationships to the development of
Clinically oriented research documents the selfhood in men and women as described by
Chodorow (1978) and Gilligan (1982). Thus it
This research was supported by a grant from the Alberta
becomes important to address substance abuse
Mental Health Research Fund. and gender as potential confounding variables in
Correspondence to; N. El-Guebaly, Foothills Hospital/ the study of ACOAs relationship problems.
University of Calgary, Department of Psychiatry, 1403 - 29 Brown (1991) suggested that those working to
Street N.W., Canary, Alberta, Canada T2N 2T9.

1406 Nady El-Guebaly et al.

clarify the nature of the relationship problems of been given special pressure for continuity
ACOAs should explore the potential value of through having been validated by both subse-
attachment theory. A recent study by Brennan, quent attachment events in the family and
Shaver & Tobey (1991) confirmed the special experiences within other relationships (i.e. the
importance of the attachment construct to the degree of success in havitig attachment needs
tmderstanding of the relationship problems of met). Thus successive relationship experiences
ACOAs. Undergraduate college students who interact with prior experiences, through the rep-
reported parental problem drinking scored high resentational model, to determine the
on both avoidant and anxious-ambivalent attach- individual's current state of mind with regard to
ment pattems. attachment.
TTiis paper furthers Brennan et al.'i explo- In the instance of ACOA individuals, contin-
ration of the relationship between attachment ued lack of success in achieving felt security
and ACOA status using an outpatient psychiatric reitiforces their pessimistic beliefs about attach-
population. It reports the results of an empirical ment. Because of their strength, these affectively
study which investigated the distinctive attach- charged beliefs about attachment exist as a
ment profile of ACOAs as compared to potential awaiting expression in current
ACONAs. relationships. In sum, the attachment experi-
ences of the past and the content of present
attachment relationships are formulated and
Attachment and parental alcoholism interpreted in terms of the ACOA individual's
Although most attachment research has con- representational model of attachment.
centrated on child-parent relationships, all One direct manifestation of the effect of these
attachment theorists acknowledge attachment to models is the defensive organization of attach-
he an important feature of adult relationships ment into panems of relating. Although
(Henderson, 1977; Weiss, 1982; Ainsworth, variously named, insecure attachment pattems
1989). Further—and critically—the function of across the life span move from the distant, de-
attachment remains unchanged from childhood tached to the close, enmeshed. In adults, Bowlby
to adulthood; that is, proximity to a special and (1977) has described three pattems of insecure
preferred other is sought or maintained in the attachment: anxious attachment, compulsive
expectation of finding security (Sheldon & West, self-reliance and compulsive care-giving. He has
1989). The sense of security in any attachment also referred to a balance between anxious and
relationship depends upon the quality of respon- angry attachment from which an ambivalent pat-
siveness experienced with that partner. tem appears to arise.
From this standpoint, the interpersonal prob- This study explored the relevance of the
lems of the ACOA may refiect adaptations to attachment construct to understanding the
and ways of dealing with a troubled familial long-term impact of alcoholism on children of
envirotiment leamed over many years alcoholics. Three hypotheses were tested.
(O'Cotinor, Sigman & Brill, 1987). Further, the Hypothesis 1: ACOAs and ACONAs score dif-
severity of the ACOA individual's interpersonal ferently on measures of attachment.
problems may reflect the rigidity and pervasive- Hypothesis 2: ACOAs demonstrate more dys-
ness of the relational difficulties within the family functional attachment styles than ACONAs.
across the span of years from childhood through Hypothesis 3: Severity of itnpact of parental
adolescence to adulthood. Long-continued and alcoholism on children is associated with severity
multiple stresses such as the inability of the of dysfunction in attachment.
alcoholic parent to respond empathetically, par-
entification of the child or repeated threats of
abandonment may lead to long-term relational Methods
difficulties. Selection of participants
These deficits and failures of the alcoholic This study was a cross sectional comparison of
parent's responsiveness are the data used by the adult children of alcoholics (ACOAs,n = 102)
child to create a representational model of self in and adult children of non-alcoholics
relation to others. Those representational models (ACONAs,n = 101). The target population con-
which are carried forward to adulthood have sisted of individuals between the ages of 21 and
Attachment among adtilt children of alcoholics 1407

65, seeking any one of a variety of short-term Sheldon, 1988; West & Sheldon-Keller, 1992)
therapeutic services of a hospital based outpa- was used to assess the component features of
tient psychiatric program (n = 118) or a attachment in adults, that is, their style of anach-
community based alcoholism treatment program ment to a peer. Drawing on the work of Bowlby
(n = 85). All such services are available without (1977), Ainsworth (1989), and Weiss (1982),
payment of a fee as part of Canada's universal West et al. operationalized the key components
health and social service system. of reciprocal attachment as self-report scales. In
Potential participants were approached at the the RAQ, an attachment figure is defined as a
hospital or treatment centre. The study vsras ex- peer who is not a member of the family of origin,
plained and informed, written consent was with whom there is usually a sexual relationship
obtained prior to proceeding. Individuals with and with whom there has been a special relation-
significant physical illness, intellectual impair- ship for at least 6 months. Instructions to
ment, or active psychoses were excluded from respondents include a description of an attach-
the study. Eighty percent of those approached ment figure as "the person you would be most
met study criteria, agreed to participate, and likely to tum to for comfort, help, advice, love or
completed the research instruments described understanding; the person you'd be most likely
below in one or two sessions separated by less to depend on, and who may depend on you for
than two weeks. Recruitment spanned a period some things; the person you feel closest to right
of 18 months. Clinical responsibility for all par- now."
ticipants remained with the clinical stafF of the Four subscales (separation protest, feared loss,
respective programs. proximity seeking, and reciprocity) relate to the
criteria of attachment and serve to distinguish
adult attachment from other social relationships.
Sample profile Two subscales (use of the attachment figure and
The sample of 203 consisted of 93 (46%) men perceived availability of the figure) relate to the
and 110 women. The mean age for both genders unique provisions offered by attachment. Finally,
was 36.6 years, mean education 14 years and four scales assess the four identified pattems
mean Blishen occupational ranks (Blishen & of dysfunctional attachment relationships for
McRoberts, 1976) 39.8 for men and 39.2 for adult: compulsive self reliance, compulsive care-
women. TTiese occupational ranks indicate lower seeking, compulsive care-giving and angry
middle and upper working class occupations re- withdrawal. The pattems, criteria and provisions
quiring 12-15 years education. Fifty-one percent are further defined in Table 1.
of those sampled were ACOAs. Sixty percent of
the men and 37% of the women were substance The RAQ consists of 46-items each rated on a
abusers. Chi-square and t-tests showed that 5-point likert-type scale. Summation scores for
ACOAs and ACONAs did not differ significantly ten separate scales are produced. Six scales of
in sex, age, education, occupation, marital status three items each relate to the unique criteria and
or substance abuse. provisions of reciprocal anachment relationships,
with scores varying from 3 to 15. Four scales of
Scores on the Millon Clinical Multiaxia! In- 7 items each relate to dysfianctional pattems of
ventory (MCMI), a clinical assessment reciprocal attachment, with scores varying from
instrument described in the measurement sec- 7 to 35.
tion, produced profiles consistent with those of a
As reported in detail in earlier publications
help-seeking population. The most prevalent dis-
(West et d., 1987; West & Sheldon, 1988; West
orders were dysthymia and anxiety. Analysis of
& Sheldon-Keller, 1992), the validity and reli-
covariance of the MCMI scores revealed no
ability of the RAQ has been established with
significant differences in disorders related to sex,
clinical and non-clinical adult populations.
age or occupation. Psychopathology, as mea-
Across these sets of subjects, coefficient alpha
sured by the MCMI, was not significantly
ranged from 0.74 to 0.85 indicating acceptable
associated with ACOA/ACONA status.
structural coherence of the scales. Test-retest
reliability (over a 4 month period) with a com-
Measurements munity sample ranged from 0.76 to 0.82 for the
(I) The Reciprocal Attachment Questionnaire scales indicating their temporal stability. Factor
(RAQ; West, Sheldon & Reiffer, 1987; West & analysis confirmed the theoretical distinction
1408 Nady El-Guebaly et al.
Table 1. Definitions of attachment pattems and dimensions

Attachment items Definitions

Compulsive self reliance Avoids turning to attachment figure for help; avoids
giving attachment figure aifection and closeness;
uncomforuble when attachment figure needs himyher
Compulsive care-seeking Defines attachment relationships in terms of receiving
care; wants attachment figure to assume responsibility
for major areas of life
Compulsive care-giving Always places highest priority on needs of attachment
figure; has feelings of self-sacrifice and martyrdom
Angry withdrawal Negative reactions to perceived unavailability of
attachment figure; generalized anger with attachment
Projdmity-seeking Tendency to reduce distance from the attachment figure
in times of stress
Separation protest Degree to which physical separation, actual or
anticipated, is perceived as threatening to the
attachment relationship
Feared loss Inability to sustain confidence in the future of the
attachment relationship
Reciprocity Extent of mutuality, that is, the comfort of the
individual in serving as a source of support for his or
het attachment figure
Use of the attachment figure Extent to which the individual asks for the attachment
figure's availability and responsiveness
Available responsiveness Extent to which the attachment figure is perceived as
reliably accessible
A copy of the RAQ is available on requestfi"omthe authors.

between the criteria and provisions of adult of 0.98 is reported in the test manual Qones,
anachment and the differentiation of the attach- 1983). Validity of the CAST has been demon-
ment pattern scales into avoidant and enmeshed strated with an adult psychiatric population
categories. Finally, a discriminant functions (Staley & el-Gueba!y, 1991) and in comparisons
analysis demonstrated the scales were highly rel- of alternatively diagnosed and matched controls
evant to the differentiation of psychiatric of children Qones, 1983). The CAST was used
outpatients from non-patients. in this study to both identify ACOAs and
For the sample in this study, Cronbach alphas ACONAs and as an indicator of severity of im-
ranged from a low of 0.61 on the 7-item compul- pact of parental alcoholism on study participants
sive care-giving subscale to a high of 0.82 on the for those who were classified as ACOAs. In the
3-item feared loss subscale. Scores on all sub- former case, ACOAs were identified by scores of
scales approximated normal distributions. 6 or higher, ACONAs by scores of 0, and those
with scores of 1-5 were considered to have an
(2) The Children of Alcoholics Screening Test imcertain status and excluded from analysis (8
(CAST; Jones, 1983) is a widely used instrument individuals were in this category). For ACOAs,
for identifying adults who have at least one alco- the full CAST score was used as an indicator of
holic parent and for assessing the severity and severity of impact.
areas of impact of parental alcoholism on the In this study, a Cronbach alpha of 0.98 was
individual. It contains 30 yes/no items. Respon- obtained for the CAST items. CAST scores of
dents who self-identify at least six items as ACOAs deviated from a normal distribution,
characteristic of their parental home are desig- however, necessitating the use of the non-para-
nated as adxilt children of alcoholics (ACOAs). A metric Spearman rho correlation in measuring
Spearman-Brown split-half reliability coefBcient the association with RAQ scores.
Attachment among adult children of alcoholics 1409

(3) The Millon Clinical Multiaxial Inventory spouse (53%) or other sexual parmer (30%). An
(MCMI; Millon, 1987) is a 175 item, true-false additional 12% identified a same sex friend as an
inventory that follows the multiaxial format em- attachment figure and 6% a relative other than
ployed in the DSM-III. Eleven personality the spouse. Eighty percent reported the attach-
disorders, nine clinical syndromes, and one ment relationship was over a year's duration, the
validity scale are provided. The MCMI scales longest having endured for 43 years. Chi-square
were constructed and validated to measure tests demonstrated no significant differences in
DSM-IIi typologies (Dana & Cantrell, 1988). the characteristics of the attachment relation-
An issue, however, is the relative lack of ships with respect to ACOA status, substance
specificity reported in Volume II of the Millon abuse or gender.
manual for the alcohol and drug subscales (Mil-
lon, 1987). The false positives and negatives are
34% and 44% respectively for the alcohol scale ACOA status and attachment pattems and
and 37% and 48% respectively for the drug dimensions
scale. Consequently, substance abuse was mea- Table 2 presents results of comparisons of RAQ
sured using twelve items from these two scales scores for the 147 ACOAs and ACONAs with
which matched with DSM-III-R criteria for sub- attachment figures. For women, ACOAs and
stance abuse. The twelve items were subjected to ACONAs were significantly different in their
tests of face validity, discriminate validity, and scores on angry withdrawal, separation protest,
internal reliability. In the first instance, the con- use of the attachment figure, and perceived
gruence of the items and DSM-III-R criteria for availability of the attachment figure. No
substance abuse was assessed by experienced significant associations were found for men.
clinicians. In the second, the ability of the twelve Analyses of variance using both ACOA status
item scale to discriminate between knovm sub- and substance abuse were conducted for males
stance abusers and non-abusers was assessed. and females separately to assess for possible in-
Finally, a Cronbach alpha of 0.89 demonstrated teractions between substance abuse and ACOA
an acceptable level of internal reliability of the status. Results indicated no significant difference
twelve-item tneasure. in RAQ scores for women based on whether they
were or were not substance abusers, nor any
interactions between substance abuse and
Statistical analyses ACOA status. Only the association with ACOA
Data were analyzed separately for males and status was significant. For men, none of the
females. Substance abuse was entered into data associations were significant.
analysis as a control to test and measure its
impaa on relationship pattems, distinct from
that of ACOA status. T-tests, analyses of vari-
Severity of impact of parental alcoholism and
ance, chi-square contingency tables and
correlation analyses were used to assess the rela-
Spearman rho correlations between CAST and
tionships between attachment, ACOA status,
RAQ scores were calculated for male and female
severity of impact of parental drinking, and sub-
ACOAs. Application of the Bonferroni correc-
stance abuse. A Bonferroni correction was used
tion required p-values at 0.005 or lower for
to protect against chance effects in multiple test-
significance at the 0.05 level. Once the correc-
ing, setting the p value at 0.05.
tion was applied, none of the correlations met
criteria for significance. Four of the correlations
Results for male ACOAs, however, approached
Presence and characteristics of attachment figure significance, suggesting further study with a
Twenty-eight percent (56) of those sampled did larger sample is warranted. These were the cor-
not have an attachment figure. Chi-square tests relations between CAST scores and compulsive
produced no significant associations between the self reliance (rho = 0.32, p = 0.036), separation
presence or absence of an attachment figure and protest (rho = 0.33, p = 0.031), lack of use of
ACOA status, substance abuse or gender. attachment figure (rho = 0.30, p = 0.048), and
For 83% of the 147 participants who did have perceived lack of availability of attachment figure
an attachment figure, attachment was to a (rho = 0.37,/! = 0.020).
1410 Nady Bl-Guebaly et al.

Table 2. T-test results for ACOA/ACONA differences in RAQ scores

Male Female

RAQ pattems
Angry withdrawal 17.86 17.00 0.67 16.44 20.03 - 2.82*
Compulsive self reliance 19.28 18.32 0.77 17.07 18.58 -1.53
ComptUsive care-giving 23.10 23.71 -0.63 24.34 24.05 0.37
Compulsive care-seeking 15.90 17.03 - 1.12 17.53 18.35 0.78
RAQ dimensions
Separation protest 7.41 7.94 -0.75 6.68 8.35 - 2.57*
Feared loss 8.38 9.21 -1.03 7.89 9.33 -2.07
Proximity seeking 8.03 8.88 -1.55 8.84 9.05 0.37
Reciprocity 5.79 5.24 1.30 4.75 5.40 -1.83
Use 7.24 6.26 1.89 5.40 6.55 -2.57*
Availability 7.34 7.29 0.08 6.6! 8.23 -2.59*
n 29 34 45 40
* p < 0.005 (required for Bonferrotii adjustment to f < 0.05).

Discussion Bowlby (1977) as separation anxiety. In particu-

Though the presence or absence of an attach- lar, the perception of the inaccessibility of the
ment relationship did not differ for ACOAs and attachment figure and the angry withdrawal of
ACONAs, for those who had an attachment these women from their attachment figure are
figure, parental alcoholism influenced the attach- analogous to Ainsworth's anxious-resistant chil-
ment style (as measured by the RAQ) with which dren who seek contact veith mother, but are
they approached their attachment partner. For contact resisting and angry during the reunion
women, the presence of an alcoholic parent was episode. This attachment style is also congruent
associated with elevated scores on angry with- with Brennan et al. 's finding of an 'anxious-am-
drawal and separation protest, and scores bivalent' pattern among their ACOA subjects.
indicating less use of the attachment figure for These findings provide empirical support for
support and a perception of the attachment Brown's (1991) argument and Bretman et cU.'&
figure as unavailable. All of these are evidence of (1991) preliminary findings that the attachment
a dysfunctional attachment style, supporting construct offers a specific, theoretically grounded
both hypotheses 1 and 2 for women. For men, way to understand and address the impact of
though there were no statistically significant rela- growing up with an alcoholic parent.
tionships, the association between certain Turning to men, though restilts are not statis-
attachment dimensions and pattems and the tically sigtiificant for a sample of this size, a
severity of the impact of the alcohol abuse (as picture of an association between greater severity
measured by the CAST score) when there was of impact of parental alcoholism and compulsive
an alcohol abusing parent approached self-stifficiency is suggested. Of note is the com-
significance. Approaching significance are the as- plementarity of the styles for men and women.
sociations between the severity of the impact of
The present study was a preliminary investiga-
alcohol abuse on the male offspring of an alcohol
tion of the utility of attachment theory in
abusing parent and elevated compulsive self re-
specifying the nature of the impact of growing up
liance, low separation protest and use of the
with an alcoholic parent. These results are lim-
attachment figure for support, and a perception
ited in their generalizability by the nature of the
of the attachment figure as unavailable. Though
sample and that of the instruments used.
hypothesis 3 is not supported, these results sug-
Specifically, the sample was drawn from a help-
gest further research, with a larger sample,
seeking adult population. DetaUs of childhood
should be pursued.
experiences with alcoholic parent(s) were un-
The attachment style which is characteristic of available, with only the full CAST score available
female ACOAs as distinct from ACONAs paral- as an indicator of severity of impact. In addition,
lels that referred to by Ainsworth (1989) and carefiil differentiation between the impact of al-
Attachment among adult children of alcoholics 1411

coholic mothers as compared to fathers, the age GiLUGAN, C. (1982) In a Different Voice: Psychological
of the child when infiuenced by parental alco- Theory and Women's Development (Cambridge, MA,
Harvard University Press).
holism, and the length of exposure to an artively HENDERSON, S. (1977) T h e social network, support
drinking parent were not available. The gender and neurosis: the function of attachment in adult
differences in our results suggest a need for \ik, British Journal of Psychiatry, 131, pp. 185-191.
further exploration of the differential impact of JONES, J. W. (1983) The Children of Alcoholics Screening
parental alcoholism on sons and daughters. Such Test: Test Manual (Chicago, Camelot Unlimited).
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