Attachment Styles and Sense of Coherence as Indicators of Treatment Adherence and Completion among Individuals with Substance Use Disorder

doi:10.21203/rs.3.rs-4723908/v1

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Attachment Styles and Sense of Coherence as Indicators of Treatment Adherence and Completion among Individuals with Substance Use Disorder

https://doi.org/10.21203/rs.3.rs-4723908/v1

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Background

Substance use disorder (SUD) is a growing public health concern in Sweden. Various treatments for SUD exist, with motivational treatment, cognitive behavioral therapy, and relapse treatment being the nationally recommended approaches. Attachment theory and the salutogenic theory with its core concept, sense of coherence (SOC) provides valuable insights into individuals’ available personal resources and their potential for adherence to treatment. The aims of the present study were to examine attachment styles (secure, insecure-avoidant, and insecure-anxious) and levels of SOC (comprehensibility, manageability, and meaningfulness) in individuals with SUD, explore potential correlations between the dimensions of these two frameworks, and assess the ability of these two frameworks to predict treatment completion.

Methods

The study employed a quantitative design. Clinical data were collected using validated self-report instruments (the Attachment Style Questionnaire and the Sense of Coherence Questionnaire) from individuals with SUD at a Swedish outpatient clinic for addiction. Statistical analyses included descriptive statistics, correlation analysis, and logistic regression.

Results

Individuals with SUD predominantly exhibited an insecure-avoidant attachment style. The four dimensions of an insecure attachment correlated negatively with overall SOC and with its dimensions, while the dimension of a secure attachment correlated positively with SOC. The strongest associations were found between the manageability dimension of SOC and all attachment styles. The insecure-anxious attachment style showed the strongest association with early dropout from treatment, while a stronger manageability was significantly associated with a higher likelihood of treatment completion.

Conclusion

The predominance of an insecure-avoidant attachment style among clients undergoing intensive, integrated treatment for SUD underscores the significance of reinforcing a secure attachment and enhancing SOC to facilitate treatment completion. This highlights the importance of comprehensive and integrated social and psychiatric care for individuals with SUD.

Attachment Styles

Integrated Intervention

Sense of Coherence (SOC)

Substance Use Disorder (SUD)

Sweden

Treatment Adherence

Treatment Completion

Attachment theory is a developmental psychological theory that was originally presented in John Bowlby’s classic work Attachment (1982). Notably, attachment is not confined to childhood; it plays a role in shaping individuals’ interactions throughout their lives, with early patterns influencing later relationships (Bowlby, 1982). This is consistent with findings from modern neurobiological research, which suggest that the brain’s responses associated with attachment styles persist into adulthood (Bailey, 2014). In other words, the way adults form relationships and respond emotionally to others is influenced by their early attachment experiences and can be observed through patterns in brain activity. However, various factors, including mental health, significant life events, and relationship experiences, can prompt changes in attachment patterns (Davila et al., 1997). Interventions that target attachment patterns can lead to changes in brain function and structure. For example, functional magnetic resonance imaging has demonstrated alterations in brain activity when analyzing attachment patterns in traumatized clients (Buchheim et al., 2008), and it has also been shown that therapeutic interventions have the capacity to modify attachment patterns (Fonagy et al., 1994). Furthermore, a longitudinal study observed changes in brain structure and connectivity that were associated with improvements in relational functioning and attachment security (Coan et al., 2006). While attachment styles can be categorized in various ways, the dimension of security versus insecurity is particularly relevant in mental health care due to its implications for trust and confidence in relationships (Bowlby, 1982). Individuals with a secure attachment style are more likely to experience psychosocial well-being than those with insecure attachment styles (Männikkö, 2001). Notably, anxiety and depression are significantly associated with an insecure-avoidant attachment style, and a secure attachment style shows no correlation with either of these psychiatric disorders (Priceputu, 2012).

The relationship between attachment style and substance use disorder (SUD) has been extensively studied (Hiebler-Ragger and Unterrainer, 2019; Schindler and Bröning, 2015). A bidirectional relationship was initially proposed; however, recent studies have indicated that insecure attachment styles may serve as vulnerability factors for substance use (Fairbairn et al., 2018). There is a higher prevalence of insecure attachment styles in the outpatient population with SUD than in individuals without SUD, and patients with SUD who have secure attachment styles exhibit lower levels of psychological distress (Gidhagen et al., 2018). Cihan et al.’s (2014) review emphasized the importance of considering attachment style and attachment-related conditions in the care of patients with SUD, underscoring the potential for addressing one of the root causes of the syndrome through attachment-focused rehabilitation efforts. This approach contrasts with traditional healthcare methods, which are primarily focused on treating symptoms. This highlights the significance of integrating attachment into the understanding of the etiology of SUD and suggests that an attachment-based approach could improve the treatability of the condition (Cihan et al., 2014). Additionally, previous research has explored how attachments influence treatment willingness among people with SUD. Findings have suggested that an individual’s attachment style is associated with both motivation for treatment and receptivity to psychotherapy. Specifically, an insecure-avoidant attachment is associated with lower treatment motivation scores and decreased openness to psychotherapy, while an insecure-anxious attachment is associated with higher treatment motivation scores and greater receptivity to psychotherapy (Tekin et al., 2021; Kealy et al., 2016). Moreover, insecure attachment styles are associated with increased difficulties in therapeutic relationships (Daniel, 2006).

Sense of coherence (SOC), a life orientation, is the core concept in the salutogenic theory. An individual’s SOC is assessed across three dimensions: comprehensibility, manageability, and meaningfulness (Antonovsky, 1987). The way people view the life affects the ability to manage tension and stress. This theory underscores the importance of strengthening SOC through interventions that focus on promoting health (Antonovsky, 1996; Bauer et al., 2020). Interestingly, SOC may serve as a mediator in the relationship of attachment and well-being (Ying et al., 2007).

Comprehensibility reflects one’s ability to understand and cope with stressful situations through the management, comprehension, and structuring of life’s challenges. Manageability pertains to an individual’s resources for problem solving and encompasses both formal (e.g., social services, care staff) and informal (e.g., family, significant others) support networks. Meaningfulness, which serves as a factor in motivation, refers to a sense that life has a purpose and significance. Individuals with high levels of meaningfulness view challenges as opportunities rather than burdens; they are driven by energy, dedication, and a desire to overcome obstacles (Antonovsky, 1987). This sense of motivation and purpose enables individuals to navigate stressful situations effectively, avoiding distress and finding meaning in adversity.

Generalized resistance resources (GRRs) and specific resistance resources (SRRs) are additional key concepts that contribute to the development of a strong SOC. GRRs are broad, wide-ranging, and overarching factors (e.g., material, ego identity, and social support). SRRs are distinct and personal factors that reflect an individual’s context and needs, such as particular skills or coping mechanisms tailored to specific stressors. The salutogenic theory emphasizes salutary factors and considers the entire person’s physical, mental, emotional, and existential aspects rather than focusing solely on the disease. It emphasizes that health promotion should target well-being rather than disease treatment.

Psychiatric disorders are often linked to weaker SOC, and individuals who undergo treatment for depression and anxiety tend to experience fewer post-treatment symptoms when they exhibit strong SOC (Paika et al., 2017; Schäfer, 2019). A strong SOC is also associated with reduced alcohol and cannabis use (Grevenstein, 2014). When individuals with SUD face challenging drug-related situations, seeking comprehensibility and manageability is crucial (Wiklund, 2008). Moreover, individuals with SUD who have stronger SOC are at reduced risk of hospital admission for comorbid psychiatric disorders (Kouvonen, 2010).

For individuals with SUD, the strength of the SOC is positively correlated with health behaviors and a positive mental attitude, particularly in terms of manageability (Curyło, 2023). Psychological distress is a risk factor for dropout and relapse among people with SUD; a stronger SOC acts as a protective factor (Bøhle, 2021). Strengthening the SOC can empower individuals with SUD to make positive choices and adopt pro-health behaviors, facilitating their journey toward a drug-free life (Curyło, 2022).

It is firmly established that SUD poses a significant risk of immense suffering and profound impairment across various aspects of life. Furthermore, it is recognized that attachment style and SOC influence not only individuals’ mental health but also their motivation for treatment and their ability to complete interventions. The lack of research examining potential associations between attachment profiles and SOC limits our understanding of how these frameworks intersect and influence mental health, treatment adherence, and outcomes in individuals with SUD.

Previous research has addressed these concepts, but there is a dearth of studies that combine them. SOC may have a mediating effect on aspects of mental health that are related to insecure attachments, such as depression. Therefore, a deeper understanding of how the combination of attachment styles and strength of SOC manifests in individuals with SUD, as well as whether specific dimensions of these frameworks show predictive capacity for the adherence and completion of treatment, would be beneficial.

This study aimed to examine attachment styles and SOC among individuals with SUD, explore potential correlations between the different attachment styles and SOC dimensions, and assess the predictive value of these frameworks regarding the completion of or early dropout from an intensive, integrated outpatient addiction treatment program.

Design and Intervention

The study utilized a quantitative methodology to analyze clinical data from individuals in an intensive, integrated psychological treatment program for SUD at a private outpatient clinic in western Sweden. These individuals were referred to the clinic through social services and are referred to as clients. Upon admission, the clients received information about the structure, rules, and ethical requirements of the intervention period. The clients had the opportunity to ask questions before the treatment commenced. They then completed a survey comprising demographic details, such as gender, marital status, age, and number of children, along with various validated measures of mental health and personality. The clients were provided with a quiet, undisturbed room to complete the survey. The intervention spanned one year, with the first four months involving the intensive, integrated treatment program, conducted five days a week. This phase included interventions such as psychoeducation, cognitive processing, modulation, problem-solving exercises, affect regulation, exposure and response prevention, behavior experiments and activation, mindfulness, skills training, standardized acupuncture, and structured yoga classes. During the remaining eight months of the program, the clients had the option to participate in weekly follow-up group sessions.

Study Population

Clinical data were collected from 2014 to 2023, from a total of 164 clients who began the treatment program. Of the 164 clients, 109 were men and 55 were women, with ages ranging from 18 to 72 (mean [M], 40.71; standard deviation [SD], 11.85) years. The majority (n = 120; 73%) were single; the rest (n = 44; 27%) were in relationships. Approximately half (n = 76; 46%) reported having children (one child on average). Half of the clients enrolled in the treatment program (82 individuals) successfully completed the four-month intensive phase of the program, resulting in a 50% attrition rate for the intervention.

Data Collection

All 164 clients who consented to participate in the standardized, integrated, intensive addiction treatment program conducted a self-assessment of their attachment styles, using the Attachment Style Questionnaire (ASQ), as part of a clinical admission survey. The Sense of Coherence Questionnaire (SOC-29) was used to measure the strength of the clients’ SOC. As there was a continuous intake to the intervention, clients entered the treatment structure at different points; therefore, they completed the SOC-29 at various times during the intervention. The attrition rate during the four-month intervention period was 40%, resulting in 98 clients who completed the SOC-29. An overview of the clients’ participation is shown in Fig. 1.

Place Fig. 1. here

Figure 1. Clients’ participation in intensive, integrated treatment over time.

Instruments

Attachment Style Questionnaire (ASQ)

This self-assessment questionnaire, rooted in attachment theory, was originally developed in English in 1994 (Feeney et al., 1994). Subsequently, an equivalent Swedish version was created in 1996 (Tengström and Håkansson, 1997). The 40-item survey assesses a respondent’s attitudes toward the self and others. Responses are given using a six-point scale, with answers ranging from “totally disagree” to “totally agree.” Three items are phrased negatively; these needed to be reversed for the analysis (Feeney et al., 1994).

The questionnaire delineates an individual’s attachment style, presenting a comprehensive overview across five dimensions: “discomfort with relationships,” “relationships as secondary,” “confidence in self and others,” “need for approval,” and “preoccupation with relationships.”

“Confidence in self and others” corresponds to a secure attachment, which is characterized by high levels of trust and security in relation to both oneself and others. Individuals with this attachment style possess the ability to initiate close relationships and undergo separations without experiencing excessive discomfort. The remaining four dimensions represent different facets of an insecure attachment. “Discomfort with relationships” and “relationships as secondary” are distinct components of an insecure-avoidant attachment and primarily measure attitudes toward others. “Discomfort with relationships” is characterized by feelings of anxiety and unease regarding close contact with others. Individuals with high scores for this dimension often respond to these feelings by maintaining distance and avoiding close bonds with others. “Relationships as secondary” is a dimension in which individuals prioritize personal achievements while maintaining independence from others. Finally, “need for approval” and “preoccupation with relationships” collectively represent an insecure-anxious attachment and primarily measure attitudes toward oneself. “Need for approval” is characterized by a significant need for approval and acceptance from others, while “preoccupation with relationships” involves seeking out others in an exaggerated manner to achieve feelings of security and belonging (Feeney et al., 1994). An overview of the dimensions of the ASQ and how they are connected to attachment styles is presented in Fig. 2.

Place Fig. 2 here

Figure 2. The dimensions of the ASQ and how they correspond with attachment styles.

Values from a reference population can be utilized in the examination of ASQ dimension scores from a study population. The Swedish manual for the ASQ provides information about the mean scores from a Swedish reference population of 90 high school and university students aged 18 to 42 years (Tengström and Håkansson, 1997). In the current study, the ASQ dimension scores of clients with SUD were compared to these reference values.

In the current study, a mean score was calculated for each of the five dimensions of the ASQ by adding the respective points and dividing that total by the number of items in the dimension. The “confidence in self and others” dimension, which represents a secure attachment, is of particular value in distinguishing between secure and insecure attachment styles. According to the guidelines, the mean score for the secure dimension must exceed 4.0 to be classified as secure. However, a prerequisite for this distinction is that the scores for the insecure dimensions must also fall at or below the levels from the reference population. Otherwise, the attachment profile is considered mainly insecure; in this case, a high value in the secure dimension can be considered a moderator that may mitigate some of the negative consequences of an insecure attachment (Tengström and Håkansson, 1997).

The Swedish version of the ASQ has shown acceptable internal consistency, with Cronbach’s alpha (α) values ranging between 0.71 and 0.84 for the five dimensions (Tengström and Håkansson, 1997). The English version of the ASQ has shown comparable levels of reliability. However, lower α values were observed within a clinical cohort (n = 158), with the “relationships as secondary” dimension exhibiting a low, unacceptable level of internal reliability (α = 0.56) (Axfors, 2013). This dimension also had the lowest internal reliability in the present study (α = 0.67); the other dimensions demonstrated acceptable levels (discomfort with relationships, 0.81; confidence in self and others, 0.83; need for approval, 0.74; preoccupation with relationships, 0.77).

Sense of Coherence Questionnaire (SOC-29)

The SOC-29, also known as the Orientation to Life Questionnaire, is a self-assessment tool that assesses an individual’s perception of comprehensibility, manageability, and meaningfulness. It contains 29 questions (11 that focus on comprehensibility, 10 on manageability, and 8 on meaningfulness) that are each answered using a 7-point Likert scale. Thirteen questions are phrased negatively and were reversed before analysis. The total score ranges from 29 to 203 points (Antonovsky, 1993). The cutoff point is not standardized and should be contextually linked to the research question. The total scale has consistently shown a high level of internal consistency, with α values ranging from 0.84 to 0.93 across several studies (Eriksson and Lindström, 2005). In the present study, the α for the SOC-29 was 0.89, indicating high internal reliability. The internal reliability of each individual SOC dimension was acceptable (comprehensibility, α = 0.69; manageability, α = 0.73; meaningfulness, α = 0.84).

Statistical Analysis

All data were processed using the Statistical Package for the Social Sciences (SPSS version 29.0.2.0, IBM). The data were tested for normality using the Shapiro–Wilk test. To address deviations from the normal distribution, non-parametric tests were consistently applied due to significant differences observed in certain dimensions of the ASQ and SOC-29. Descriptive statistics, including Ms, SDs, and percentages (%), were employed. All statistical analyses were carried out with the level of significance set at p < 0.05. The relationships between attachment styles and SOC dimensions were assessed using Spearman correlation analyses. The strengths of the correlations were interpreted as follows: r < 0.1, no association; r = 0.1 to 0.3, weak association; r = 0.3 to 0.6, moderate association; r > 0.6, strong association (Akoglu, 2018). A logistic regression analysis was conducted with early dropout (yes/no) as the dependent variable and attachment as a predictor. This test was not replicated for the SOC-29, because at this point in the intervention, the clients had not completed this questionnaire. Additionally, a logistic regression analysis was conducted with the completion of the intensive intervention (yes/no) as the dependent variable and attachment and SOC dimension scores as predictor variables.

Attachment Styles and SOC Scores

Descriptive statistics for the study population with regard to the dimensions of the ASQ and SOC-29 are presented in Tables 1 and 2. A visual representation of the clients’ attachment profiles is shown in Fig. 3.

Place Tables 1 and 2 here

Table 1. Attachment styles and ASQ dimension scores among the study population.

Attachment Style	ASQ Dimension	M (SD)	Md	Min–Max
Insecure-avoidant	Discomfort with relationships	4.02 (0.87)	4.10	2.10–5.90
Insecure-avoidant	Relationships as secondary	2.82 (0.85)	2.71	1.00–5.29
Secure	Confidence in self and others	3.80 (0.96)	3.88	1.25–5.75
Insecure-anxious	Need for approval	3.60 (0.98)	3.71	1.43–6.00
Insecure-anxious	Preoccupation with relationships	3.63 (0.97)	3.56	1.25–5.75

ASQ=Attachment Style Questionnaire; M=mean; SD=standard deviation; Md=median.

Table 2. SOC-29 scores among the study population.

SOC-29 Dimension	M (SD)	M_A	Md	Min–Max
Total SOC-29 score	121.07 (21.49)	4.17	118.50	77–172
Meaningfulness (8 items)	37.55 (7.87)	4.69	37.00	20–54
Comprehensibility (11 items)	40.90 (7.85)	3.71	40.00	23–55
Manageability (10 items)	42.62 (8.55)	4.26	42.50	25–64

SOC-29=Sense of Coherence Questionnaire; M=mean; SD=standard deviation; M_A=mean adjusted for the number of items within the dimension; Md=median.

The clients exhibited moderate mean scores for four of the five dimensions of the ASQ (Table 1, Fig. 3). These dimensions included “confidence in self and others,” “discomfort in relationships,” “need for approval,” and “preoccupation with relationships.” The “relationships as secondary” dimension exhibited the lowest mean score.

Place Fig. 3 here

Figure 3. Attachment profiles of the study and reference populations.

The clients in the present study indicated a higher prevalence of insecure-avoidant attachments than the reference population. In the present study, the mean scores for “discomfort with relationships” and “relationships as secondary” were 0.8 and 0.67 points higher than the reference values, respectively. The present study population exhibited a lower prevalence of secure attachments than the reference population, with a mean score 0.65 points lower than the reference value. The prevalence of insecure-anxious attachments was slightly higher in the present study population than in the reference population, with differences of 0.10 and 0.03 points for the “need for approval” and “preoccupation with relationships” dimensions, respectively.

The clients’ mean SOC-29 score was 121. When adjusted for the number of items included in each dimension, the corrected mean scores were comparable across all dimensions. The highest score for the present study population corresponded with meaningfulness (M_A=4.69), and the lowest corresponded with comprehensibility (M_A=3.71) (Table 2).

Associations Between Attachment Styles and SOC Dimensions

The correlations between attachment styles and SOC dimensions are presented in Table 3.

Place Table 3 here

Table 3. Strength and significance of associations between attachment styles and SOC.

SOC-29 Dimension	M (SD)	M_A	Md	Min–Max
Total SOC-29 score	121.07 (21.49)	4.17	118.50	77–172
Meaningfulness (8 items)	37.55 (7.87)	4.69	37.00	20–54
Comprehensibility (11 items)	40.90 (7.85)	3.71	40.00	23–55
Manageability (10 items)	42.62 (8.55)	4.26	42.50	25–64

SOC-29=Sense of Coherence Questionnaire; M=mean; SD=standard deviation; M_A=mean adjusted for the number of items within the dimension; Md=median.

A secure attachment style was positively associated with total SOC and all three SOC dimensions, with significant and moderately strong associations between a secure attachment and total SOC, meaningfulness, and manageability. The association between a secure attachment style and comprehensibility was weak. Conversely, insecure attachment styles were negatively associated with total SOC and each of its dimensions. Generally, total SOC and manageability had the strongest associations with attachment style, demonstrating a moderate effect size with each of the attachment styles. The dimension of comprehensibility exhibited the weakest associations; its association with “relationships as secondary” did not reach statistical significance.

The Predictive Capacity of Attachment Styles and SOC for Early Dropout and Treatment Completion

Due to the high dropout rate observed during treatment (40%), a logistic regression analysis was conducted to investigate whether any of the dimensions of the ASQ could predict early dropout. While none of the dimensions showed a statistically significant association with early dropout, “preoccupation with relationships” demonstrated a trend that neared significance (p = 0.07). Every 1-point increase in the “preoccupation with relationships” dimension was coupled with a 47% increase in the likelihood of a client dropping out during the course of the intervention (Exp[B] = 1.470).

In terms of predictive capacity for fully completing the intervention, no attachment style was found to have a significant predictive value. Similarly, the SOC dimensions of meaningfulness and comprehensibility did not demonstrate any significant predictive value. However, for each 1-point increase in manageability, there was a significant (p = 0.048) increase of approximately 10% in the likelihood of a client completing the intervention (Exp[B] = 1.097).

Insecure Attachment Styles Among Clients

The clients in the present study predominantly exhibited an insecure-avoidant attachment style. This was particularly clear from the dimensions that assessed the need for interpersonal distance. While a minor elevation was also observed in one of the two dimensions associated with an insecure-anxious attachment, this deviation was minimal in comparison to the scores of the reference population. This suggests that it is specifically an insecure-avoidant attachment style, not a general insecure attachment style, that is representative of the study population. However, the slight increase in insecure-anxious scores may support an overall insecure pattern, particularly when combined with the significantly elevated scores for the dimensions associated with an insecure-avoidant attachment. The insecure attachment style of the clients in the present study was further reinforced by their lower scores in the secure attachment style dimension in comparison with the reference population (Tengström and Håkansson, 1997).

A higher prevalence of insecure attachments among individuals with SUD has been previously described (Gidhagen et al., 2018). Individuals with an insecure-avoidant attachment style often prefer to maintain distance from others and adopt coping approaches that depend less on other people (Tengström and Håkansson, 1997). They tend to avoid close relationships, which may serve as a protective mechanism against perceived vulnerability in relationships. As a result of adopting a generally distant and avoidant approach toward others, it may be reasonable to assume that individuals with SUD struggle to invest trust in care settings that rely on interpersonal relationships, including therapeutic relationships in the treatment of SUD, other forms of psychiatric care, and general healthcare. Considering that an insecure attachment may be a vulnerability factor for SUD and that SUD poses an elevated risk for comorbidities, attachment style potentially affects both the risk of developing SUD and one’s ability to engage in treatment (Fairbairn et al., 2018; Männikkö, 2001; Priceputu, 2012). Although the present study did not assess health-related treatment outcomes, its confirmation of a predominantly insecure attachment style among clients with SUD underscores the potential benefit of incorporating considerations of attachment style in the treatment of SUD.

Associations Between Attachment Styles and SOC Dimensions

The present study indicates that a secure attachment is positively associated, and insecure attachment styles are negatively associated, with overall SOC and all three SOC dimensions. A secure attachment style, characterized by confidence in oneself and others, can be considered a GRR. This is in line with the salutogenic theory and the definition of SOC — “…the extent to which one has a pervasive, enduring though dynamic feeling of confidence…” (Antonovsky, 1987, p. 19). Individuals with secure attachments view themselves and others positively, facilitating better stress management and coping strategies. Overall, a secure attachment enhances both GRRs and SRRs and may act as an SRR in particular situations providing emotional support and fostering strong interpersonal relationships.

Previous research has highlighted the role of attachment styles in shaping SOC (Huon, 2000), which, in turn, may mediate the impact of an insecure attachment on subjective well-being (Butor-Bhavsar, 2013). Particularly notable in the context of adult clients with SUD are the significant and moderately strong associations between attachment styles and manageability, as shown in the present study. This suggests that manageability has the most pronounced influence on perceived health of the three dimensions of SOC. Previous studies have demonstrated that a more secure attachment style and a stronger SOC might have potential benefits for health and well-being (Männikkö, 2001; Curylo et al., 2022); the current findings highlight the potential advantages of integrating interventions aimed at enhancing secure attachments and SOC into the treatment of SUD. The maintenance of good health requires the ability to effectively manage stressful situations (Antonovsky, 1987). Therefore, supporting individuals with SUD in strengthening their sense of manageability, helping them identify and utilize both personal and formal resources, is crucial. This support enables these individuals to effectively manage their situations and improve their health.

Moreover, SOC has been identified as a significant and central aspect of recovery capital, which encompasses both internal and external resources that support long-term recovery from SUD, including cultural, physical, human, and social capital. A moderately-to-strongly positive correlation between recovery capital and SOC suggests that strengthening SOC can equip individuals with additional resources to help them manage situations related to substance use (Chen and Gueta, 2020). By adapting a salutogenic perspective, individuals with SUD can develop a stronger SOC through coping strategies for better perceived health. Previous research has shown an association between improved SOC and better subjective health, including mental health, physical health, quality of life, and well-being (Eriksson and Lindström, 2006); this reinforces the positive effects of integrating a salutogenic perspective for clients undergoing interventions. From a care science perspective, an understanding of the possible impacts of attachment style and SOC on an individual’s preconditions for treatment and health has the potential to provide psychiatric and health care professionals with valuable insights into the individual’s coping mechanisms, thereby improving the conditions for tailored and person-centered care. This underscores the potential benefits of incorporating elements from these frameworks into interventions for SUD and future research to further explore their interconnectedness.

Prediction of Early Dropout and Treatment Completion

During the four-month, intensive, integrated treatment intervention for SUD, a substantial portion of clients opted to discontinue the program; 40% ceased treatment before completing the SOC-29 questionnaire. The observed correlation between early dropout and a predominantly insecure-anxious attachment style, notably within the “preoccupation with relationships” dimension, suggests that individuals who tend to excessively seek connection with others may not find this type of intervention suitable. However, it is important to interpret this result with some caution, as the correlation approached but did not reach significance (p = 0.07). While we cannot definitively explain why an insecure-anxious attachment was linked with early dropout from the intervention, a potential explanation may lie in the characteristic traits of this attachment style. Specifically, the dimension “preoccupation with relationships,” as described by Tengström and Håkansson (1997), is characterized by an exaggerated fixation on relationships, where individuals seek intense contact to fulfill their needs for security in interpersonal connections. Given the intensity of the integrated treatment program, which involved active interventions five days per week (Bador and Kerekes, 2020), certain aspects of this format may have been overwhelming for these clients. Additionally, this group may have been particularly sensitive to staff turnover or other group-specific dynamics.

Other studies involving individuals with SUD who participated in such programs have reported similarly high dropout rates. For example, a previous study on 12-step programs indicated a dropout rate of 57.3% during the initial three months of treatment (Deane et al., 2012), while another study reported a 40% dropout rate over the course of an entire year (Kelly and Moos, 2003). While 12-step programs are not directly comparable to the intensive, integrated cognitive behavioral therapy that was employed in the current study, these findings suggest that the treatment of SUD is generally demanding and may lead to a high dropout rate. By the end of the intervention period in the current study, the overall dropout rate had risen to 50%, with only half of the total clients completing the four-month intervention.

Notably, treatment completion was significantly associated with the SOC dimension of manageability. This suggests that the intervention may have been demanding and stressful in terms of individuals’ abilities to manage their situations, since a higher manageability score was associated with an increased likelihood of a client completing the entire four-month intervention. Specifically, each additional point in the manageability dimension was associated with a 10% increase in the likelihood of treatment completion.

In Sweden, social services bear most of the responsibility for the treatment of SUD. Social services operate in accordance with the Social Services Act (SFS: 2001:453, 3. Ch., 7§), which mandates the dissemination of knowledge regarding the harmful effects of substance use and available assistance options. This is complemented by an emphasis on voluntary participation (SFS: 2001:453 1. Ch., 1§). The results of the present study may indicate that social services fulfill their duties by assisting clients with SUD in achieving comprehensibility, which involves understanding their situation and seeking help voluntarily through an intensive, integrated treatment program, and meaningfulness, which is related to the clients’ motivation and purpose for ceasing substance use; this is a possible explanation to why the meaningfulness dimension did not predict treatment completion. Currently, the Swedish National Board of Health and Welfare’s (2019) guidelines recommend motivational treatment for SUD. The intervention in this study included components of motivational interviewing as part of the integrated, cognitive-behavioral-therapy–based intervention. Interventions that focus on enhancing overall SOC and the dimension of manageability may equip clients with the necessary resources to manage their situations, thereby increasing the likelihood of treatment completion. Then, treatment completion and continuous support may further increase their SOC, improving their changes of sustaining a long-term drug-free lifestyle (Chen and Gueta, 2020). Additionally, in a previous study by Curylo et al. (2023) that involved individuals undergoing interventions for alcohol addiction, manageability significantly predicted positive mental attitudes, preventive behaviors, health practices, and health behaviors.

The integrated, intensive, cognitive-behavioral-therapy–based intervention program in the present study utilized the flexibility that is inherent in cognitive behavioral therapy. The intervention incorporated elements of psychoeducation sessions, mindfulness and relaxation techniques, and social competence training. Psychoeducation equips clients with coping strategies and problem-solving techniques for managing stressful situations. These methods are closely linked to overall SOC and the dimension of manageability. Mindfulness practices, relaxation, and breathing exercises, which were all incorporated separately in the program and collectively in its yoga classes, have a strong capacity to reduce stress, enhance self-control, and foster self-responsibility, leading to improved coping and SOC (Kerekes et al., 2019; Langeland et al., 2022). Social competence training connects clients with peers who are also receiving treatment, fostering solidarity and enabling them to provide support and share experiences, which also enhances SOC (Mattila et al., 2011). This type of integrated, intensive intervention has the ability to decrease anxiety and depression (Bador and Kerekes, 2020), which can also impact SOC. Individuals with psychiatric disorders face a higher risk of dropout from SUD treatment and have an elevated risk of relapse (Brorson et al., 2013; Andersson et al., 2019). This suggests that interventions aimed at enhancing the mental health aspects of clients with SUD may also reduce their risks of relapse and dropout from treatment. Strengthening SOC may contribute to the achievement of this goal. The integrated, intensive intervention program previously demonstrated a significant decrease in hopelessness alongside increases in self-esteem and hope among clients (Bador and Kerekes, 2020). Strong self-esteem and GRRs serve as protective shields against psychiatric distress; when combined with strong SOCs, they equip individuals with SUD to better navigate stressful situations (Antonovsky, 1987; Bøhle et al., 2021). This implies that upon the completion of treatment, individuals with SUD experience enhanced self-esteem and reduced psychiatric distress, thereby lowering the risks of dropout and relapse (Brorson et al., 2013).

SOC serves as a predictive factor for levels of hope (Yalnizca-Yildirim et al., 2023). Additionally, from a caregiver perspective, fostering hope among clients with SUD can contribute to feelings of meaningfulness and motivation, empowering them to regain control over their lives (Wiklund, 2008). Therefore, formal contacts, such as caregivers and social services staff, may act as SRRs and assist clients with SUD in improving their manageability. These findings underscore the importance of both strengthening SOC and enhancing psychological well-being in SUD treatment. This may reduce the likelihoods of dropout and post-treatment relapse and increase the chance of treatment completion, potentially giving clients with SUD a better chance at a drug-free life.

Strengths and Limitations

This study possesses several strengths that enhance its credibility and applicability. First, the robust data collection process leveraged clinical data from a substantial sample size of 164 individuals over nearly a decade (2014–2023), ensuring a comprehensive and representative dataset. The utilization of well-validated instruments—the ASQ and SOC-29, which are known for their high levels of internal consistency—strengthens the reliability of the results.

The systematic approaches employed in the data collection and analysis further bolster the validity of the present study.

However, the study is not without its limitations. There was a significant gender imbalance in the sample, with a predominance of male participants (109 men versus 55 women), which could affect the generalizability of the findings and underscores the need for gender-specific analyses in future research. Furthermore, the study did not account for socioeconomic variables (e.g., education level, salary, and employment status), factors which may influence treatment outcomes. Examining these factors in future research may provide a more nuanced understanding of the impact of socioeconomic status on the effectiveness of treatment.

Another limitation is the varied timing of the completion of the SOC-29 questionnaire, which may have introduced bias; the ongoing intervention could have influenced the SOC scores prior to the self-assessment. The administration of the SOC-29 questionnaire at only one point during the intervention further limited our ability to assess changes over time; pre- and post-intervention measurements would provide more robust insights into the treatment’s impact on overall SOC and its dimensions.

Additionally, the “relationships as secondary” dimension of the ASQ exhibited an α value below the acceptable level; while this is consistent with previous findings, it suggests potential issues with item formulation or the applicability of this dimension in measuring attachment in a Swedish cohort. The absence of definitive cutoff and reference values for the SOC-29 questionnaire complicates the categorization of the study population’s SOC as weak or strong, necessitating caution in interpreting the SOC-29 scores.

Individuals with SUD who underwent intensive outpatient treatment in Sweden predominantly exhibited insecure attachment patterns, particularly an insecure-avoidant style, which aligns with the results of previous research. This suggests potential challenges for these clients in forming interpersonal relationships within healthcare settings due to the emotional distance associated with this attachment style. Clients’ attachment styles may impact the processes and effectiveness of treatment for SUD.

Additionally, the present study confirmed associations between attachment styles and the SOC framework, particularly with SOC as a whole and its dimension of manageability. Building upon previous research that elucidated the relationship between these constructs, the findings of the present study indicate that addressing attachment patterns in psychiatric care may improve SOC and enhance treatment outcomes.

Ultimately, the study indicated that an insecure-anxious attachment style was associated with early treatment dropout, while higher scores for the manageability dimension of SOC were associated with a significantly increased likelihood of treatment completion. Given the prevalence of high dropout rates from SUD interventions, these findings may pave the way for novel treatment approaches. Interventions that aim to improve secure attachment styles and enhance SOC among clients with SUD could be deliberately integrated into intervention strategies, potentially leading to improved treatment adherence and outcomes while also fostering better perceived health.

Recommendations for Practical Application

Practical implications stemming from the findings of this study highlight the importance of considering attachment styles in the treatment of clients with SUD. As evidenced by the predominantly insecure attachment style observed in this study, particularly the insecure-avoidant subtype, many clients with SUD may feel discomfort when it comes to forming and maintaining interpersonal relationships. This poses significant challenges in therapeutic settings, where the success of treatment often hinges on the quality of the therapeutic relationships.

Understanding each client’s unique attachment profile, as facilitated by the intensive, integrated intervention approach employed in this study, provides valuable insights for tailoring intervention strategies. By delving into the specifics of each client’s attachment style, including its dimensions and potential challenges, care providers can better anticipate and address the needs of clients with SUD. This deeper understanding allows for the establishment of more effective therapeutic relationships and can inform the design of interventions that resonate with individuals’ attachment-related struggles. For care providers without access to such detailed insights, awareness of the prevalent insecure attachment style among clients with SUD can still be invaluable. This awareness enables caregivers to approach interventions with a nuanced understanding of the attachment-related difficulties that their clients may face. By recognizing and acknowledging these challenges, caregivers can adapt their approaches to treatment, fostering supportive environments that align with the principles of person-centered care.

Furthermore, the finding that higher levels of manageability are associated with an increased likelihood of treatment completion suggests the importance of focusing on interventions that bolster clients’ sense of manageability. This could involve increasing psychoeducational components in the interventions, thereby supporting the development of coping skills and encouraging social support networks.

Suggestions for Further Research

Both attachment style and SOC contribute to an individual’s ability to manage stress and challenges, and aspects of both frameworks promote mental health and overall well-being; these are important components to consider in a client’s recovery from SUD. Further exploration of the connections between these frameworks holds promise for uncovering novel intervention strategies that integrate attachment and SOC concepts in the treatment approaches that diverse healthcare and social care professionals employ, thereby enhancing the effectiveness of interventions for individuals with SUD.

Additionally, we suggest that further research should address the possible impacts of socioeconomic factors on treatment for SUD. Further analysis or replication studies with larger samples may also be necessary to validate the relationship between attachment style and early dropout from treatment. Further exploring this connection, as well as other potential moderators or mediators of the relationships between attachment styles and SOC and their predictive capacity on treatment completion and dropout, could offer deeper insights into the underlying mechanisms of these aspects and potentially improve the treatment of SUD.

Finally, the current study did not investigate the actual outcome of the intensive, integrated treatment upon the clients’ mental health or changes in attachment or SOC. Therefore, future research should include longitudinal studies to evaluate these impacts.

Ethics approval and consent to participate

The outpatient clinic received approval from the Swedish Ethical Review Authority to use the collected clinical data for research and development (reference number 2022-04639). This approval ensured adherence to the Declaration of Helsinki (World Medical Association, 2022). The treatment intervention was legally compliant and adhered to the standards of good quality outlined in the Swedish Social Services Act (SFS 2001:453, 3. Ch., 3§) and the Swedish Health and Medical Services Act (SFS 2017:30, 5. Ch., 1§, 1 point). Informed consent was obtained from all participants prior to their involvement in the study. Upon admission to the treatment program, all clients received both written and verbal information regarding the potential use of their clinical data for research and development. The clients were given the option to consent to or decline this use, with no risk of the decision affecting their participation in the treatment program. All paper-based client data and documentation are securely stored in accordance with the Swedish Patient Data Act (SFS 2008:355). Once a year, paper-based clinical data are transferred to an Excel file and pseudonymized. The electronic dataset does not contain any personal information that could lead to the identification of the individuals.

Consent for publication

All authors have read and approved the final manuscript. We confirm that we have obtained consent from all participants involved in the study and that all authors consent to the publication of this manuscript in the journal Addiction Science & Clinical Practice.

Availability of data and materials

The data that support the findings of this study are available from KB, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of KB.

Competing interests

KB is the director of the addiction outpatient clinic. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions

NK: Conceptualization, Formal analysis, Methodology, Supervision, Writing – original draft, Writing – review and editing.

KB: Conceptualization, Data curation, Project administration, Writing – review and editing.

CS: Formal analysis, Visualization, Writing – original draft, Writing – review and editing.

LH: Formal analysis, Visualization, Writing – original draft, Writing – review and editing

SL: Supervision, Writing – review and editing.

ME: Supervision, Writing – review and editing.

Acknowledgements

We would like to express our gratitude to all the clients who responded to the questionnaires.

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Competing interest reported. KB is the director of the addiction outpatient clinic. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

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Attachment Styles and Sense of Coherence as Indicators of Treatment Adherence and Completion among Individuals with Substance Use Disorder

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Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Material and Methods

Design and Intervention

Study Population

Data Collection

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Instruments

Attachment Style Questionnaire (ASQ)

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Sense of Coherence Questionnaire (SOC-29)

Statistical Analysis

Results

Attachment Styles and SOC Scores

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Associations Between Attachment Styles and SOC Dimensions

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The Predictive Capacity of Attachment Styles and SOC for Early Dropout and Treatment Completion

Discussion

Insecure Attachment Styles Among Clients

Associations Between Attachment Styles and SOC Dimensions

Prediction of Early Dropout and Treatment Completion

Strengths and Limitations

Conclusions

Recommendations for Practical Application

Suggestions for Further Research

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors' contributions

Acknowledgements

References

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