Literature Review: Attachment-Based Therapy as an Active and Preventative Treatment Modality against Alcohol Use Disorder (AUD) for Adult-Child Caregivers of Alzheimer’s and Dementia Patients ()
1. Introduction
Alcohol abuse and alcohol use disorders (AUD) account for the death of over three million people each year (National Center for Drug Abuse Statistics [NCDAS], 2022). Furthermore, there are 14.8 million individuals who are diagnosed with AUD (NCDAS, 2022). However, treatment approaches for AUD are also currently dominated by short-term symptom-focused approaches (Fletcher et al., 2014).
Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI) are two of the most evidence-based treatment methods used for outpatient and inpatient addiction treatment (Fletcher et al., 2014), and they will be the focal comparison for this review. CBT focuses on altering cognitive distortions that encourage individuals’ behaviors and substance use (American Psychology Association [APA], 2017). MI focuses on an individual’s perceptions and readiness around change and substance use (Hamera, 2014). CBT and MI treatment modalities are both behaviorally short-term focused, which can be problematic for treatments that can last for an extended period (Fletcher et al., 2014). Although relapse is viewed as a part of recovery, 70% of people struggling with alcohol abuse will relapse at some point and time. Moreover, over 30% of people who attempt to stop drinking and stay sober relapse within the first year (Recovery Village, 2022).
Despite a multitude of cognitive and behaviorally focused treatment modalities developed, most individuals with AUD in the United States go untreated, and they try to deal with their alcohol use and dependence on their own (Nation Institute on Alcohol Abuse and Alcoholism [NIAAA], 2022). CBT and MI have demonstrated effectiveness in treating AUD in individual and group settings; however, they both still have limitations.
Although CBT addresses current problems and focuses on specific issues, it fails to address possible underlying causes of mental health conditions such as childhood trauma (NHS, 2019). MI has shown effectiveness as a harm-reduction approach for individuals with high-risk alcohol use problems. It helps individuals build motivation to reduce risky behaviors and increase treatment engagement versus no treatment (Lundahl & Burke, 2009). However, MI does not always work well with clients with trauma and depression due to a variance in the level of motivation (Hogden et al., 2012). Recognizing the limitations of CBT and MI, it is now essential to begin exploring more attachment-based theories since attachment acknowledges the implications of childhood, interpersonal relationships, emotional processing, and communication regarding behavior and changing behavior (Johnson, 2019).
According to the 2022 National Survey on Drug Use and Health (NSDUH), of the 2.2 million people aged 12 and older who had alcohol use disorder in the past year, only 7.6% received alcohol use treatment during that time (NIAAA, 2022). Research has also shown that grief increases the risk of SUD (Caparrós & Masferrer, 2021; Sung et al., 2011). More specifically, people suffering from more prolonged and unrelenting grief are more vulnerable to developing an addiction as they try to distract themselves from their mourning (Rachamim et al., 2021).
A population that finds themselves in a position dealing with grief that is more prolonged and unrelenting is family caregivers (Paun et al., 2014), more specifically, family caregivers for individuals with Alzheimer’s and Dementia. About 80% of individuals with Alzheimer’s or Dementia receive care in their homes, and each year more the 16 million Americans provide more than 17 billion hours of unpaid care to their family and friends with Alzheimer’s or Dementia (Centers for Disease Control and Prevention [CDC], 2019). The burden of caring for individuals with Alzheimer’s or Dementia has increased dramatically over the years compared to other diseases (Alzheimer’s Association, 2020). One study showed that caregiver burden increased with the severity of their disease. Furthermore, adult-child caregivers experienced higher levels of burden in comparison to spousal caregivers despite spending less time as the caregiver (Reed et al., 2014).
2. Caregiver Burden
Caregiver burden is the accumulated strain a caregiver experiences during the caregiving process. Moreover, it has been shown to directly impact caregivers’ physical and psychological health (Liu et al., 2020). With subjective (emotions and feelings around the caregiving role) and objective (time and finances) layers of strain and burden, the caregiver burden is viewed as something complicated and multidimensional (Flyckt et al., 2015; Liu et al., 2020). Furthermore, findings have suggested that caregiver burden increases the risk of problematic alcohol use and AUD (Rospenda et al., 2010).
3. Screening for Alcohol Misuse
There are a few different alcohol screening measures developed, like the 10-item AUDIT, AUDIT-C (a shortened version of the AUDIT), and the CAGE (Bush et al., 1998; Frank et al., 2008; U.S. Department of Veteran Affairs, 2018). However, this review will focus on the AUDIT-C based on the nature of what the AUDIT-C precisely captures in its measure.
The AUDIT-C is a brief alcohol screening instrument used to help identify hazardous drinkers who may have AUD or alcohol abuse or dependence. It is a three-question test that is scored on a 0-12 point scale, with a score of 4 or more indicating hazardous drinking or AUD or men and a score of 3 indicating the same for women (U.S. Department of Veteran Affairs, 2018). The AUDIT-C questions are pictured below (Corcorran & Ramers, 2020) (See Figure 1).
The AUDIT-C was created to help identify patients with heavy drinking habits and alcohol dependence. Furthermore, it is more reliable in screening for heavy drinkers and alcohol dependence than other popular screening measures like the 4-item CAGE (Bush et al., 1998). Through numerous studies and testing, the AUDIT-C has also proven its reliability and validity across diverse racial and ethnic groups (Bush et al., 1998; Frank et al., 2008; U.S. Department of Veteran Affairs, 2018).
Figure 1. AUDIT-C questionaire for detecting alcoholism.
4. Influence of Attachment
Recent studies have found that insecure attachments, characterized as avoidant-insecure and disorganized-insecure attachment styles, are closely linked to the presence of AUD (Vungkhanching et al., 2004; Wyrzykowska et al., 2014). Individuals in the study with AUD failed to have secure attachments, which often manifested as mistrust in interpersonal relationships and avoidance of closeness (Vungkhanching et al., 2004; Wyrzykowska et al., 2014).
Attachment-based therapy can help you address some of the subconscious, lingering issues an individual may have from their childhood that impact their attachment and ability to form meaningful relationships and emotionally regulate as an adult (Gould, 2021). Therefore, this review will look at the merit of utilizing attachment-based therapy (ABT) as an active and preventative treatment modality against AUD for adult-child caregivers of Alzheimer’s and Dementia patients.
5. Attachment Theory
As stated before, CBT and MI are the dominant evidence-based short-term behavior/symptom-focused treatment methods for AUD (Fletcher et al., 2014). However, considering the limitations of CBT and MI respectfully (NHS, 2019; Hamera, 2014) and current relapse rates (Recovery Village, 2022), there is a need to explore treatments that encourage more long-term change for individuals and how they interact with the world, like attachment-based treatments (Bowlby, 1977).
Attachment theory was initially developed by John Bowlby and focused on long-term relationships and emotional bonds between people (Bowlby, 1977). Bowlby (1977) described attachment as a lasting psychological connectedness between individuals that impacts how an individual’s sense of self develops in relation to others. Bowlby (1977) asserted that infants form attachment bonds based on their relationship with their caretakers. Over time, children internalize this attachment process and start interpreting and responding to their caretakers’ behaviors (Li, 2020). This phenomenon, known as Bowlby’s internal working model (IWM), examines how a child forms expectations and uses them for planning and deciding their actions and behaviors with others (Li, 2020).
Based on the IWM and attachment, Ainsworth and other researchers identified four attachment styles: secure, ambivalent-insecure, avoidant-insecure, and disorganized-insecure (Ainsworth et al., 1978; Fletcher et al., 2014). When children do not receive responsive parenting, they develop defensive strategies that protect them from being hurt and disappointed (Fletcher et al., 2014). With an ambivalent-insecure attachment style, an individual seeks a lot of attention and reassurance because they fear rejection. An avoidant-insecure attachment style is the opposite of an ambivalent-insecure attachment. An individual experiences an internal conflict with wanting to be loved and cared for but also being afraid, holding distrust, and feelings of unworthiness (Fletcher et al., 2014; Ingham, 2019). On the other hand, a dismissive attachment style protects an individual because they stop establishing expectations and relying on others, depending on themselves to cope with stressors in life (Diamond et al., 2021).
When individuals have an insecure attachment style, they lack trust and a sense of security with others, which would have typically allowed for healthy emotional regulation. Furthermore, they struggle with interpersonal problem-solving, which puts them at risk of developing negative coping and self-regulation habits like alcohol use (Diamond et al., 2021).
Attachment styles are the IWM which guide individuals’ quality of relationships with others and their social functioning (Khodarahimi et al., 2016). If our early attachments are secure, we learn to access and communicate adaptive feelings, thoughts, and behaviors. In contrast, if our early attachment experiences are insecure, we may struggle with dysregulated, maladaptive emotions and have difficulties in our intimate relationships (Costello, 2013).
6. Attachment-Based Therapy and AUD Treatment
Attachment-based therapy (ABT) is founded on the study of attachment theory, which suggests that a strong early attachment to a primary caregiver is a primal necessity for all individuals’ healthy growth and development (Bowlby, 1977). Children with a strong sense of security founded on supportive and loving relationships are more equipped to interact in a healthy way with their environment (Ainsworth et al., 1978; Goldstein, 2022).
ABT is a brief process-oriented therapy approach that explicitly targets thoughts, feelings, communications, behaviors, and interpersonal exchanges that individuals have learned either to suppress, avoid or amplify because of early attachment experiences (Costello, 2015). Below are the two main aims of ABT and what the application may look like with adult-child caregivers and assessing for AUD:
Step 1: The first step is for the therapist and client to build a good rapport and secure attachment (Ainsworth et al., 1978; Diamond et al., 2021; Goldstein, 2022). The quality of the therapeutic relationship is an essential factor in predicting the success of therapy. The therapist wants to ensure the client feels understood and supported (Costello, 2015; Diamond et al., 2021; Goldstein, 2022).
Example: The therapist will begin by administering the AUDIT-C to Client X and will discuss the results with them. Then the therapist will assess the objective and subjective burden and strain that Client X has been experiencing in their adult-child caregiver role. The therapist will encourage Client X to express any feelings and experiences that they have not been able to share with others safely. The therapist will also assess Client X’s childhood experiences and their relationship with their primary caregiver. The therapist will position themselves as a secure base for Client X, attuning to the needs and emotions of Client X with empathy, validation, and acceptance to create a secure bond, build rapport, and develop a healthy therapeutic relationship.
Step 2: In the second step, the therapist would begin to work towards helping the client to reclaim and strengthen adaptive capacities (Costello, 2015; Diamond et al., 2021). Once they have a secure bond, the therapist can model healthy thoughts and behavior patterns the client never experienced due to attachment injuries. The client would begin to learn healthier ways to respond to their environment (Costello, 2013; Costello, 2015; Goldstein, 2022). Together, the therapist and client would figure out precisely what the client has been unable to safely think, feel, perceive, communicate, or do. Furthermore, moving forward from that acknowledgment, the client would learn new and healthier ways to regulate emotions and soothe themselves, along with newly formed relationship skills to practice in their environment (Costello, 2015; Diamond et al., 2021; Goldstein, 2022).
Example: The therapist and Client X will work on identifying and linking the attachment injuries that Client X experienced as a child and Client X’s current patterns in behavior. If Client X has risky alcohol use or AUD, the therapist and Client X will work together to understand how Client X’s alcohol misuse is a maladaptive coping strategy. The therapist will help Client X identify their attachment style and increase emotional awareness. The therapist will then model healthy thoughts and behavior patterns for Client X and allow them to have corrective experiences around their attachment injuries in therapy. As Client X learns new adaptive capabilities, emotional awareness, and regulation, they will be encouraged to practice what they have learned in therapy in their relationships and adult-caregiver role.
With individual adults, the therapist aims to help the client overcome the effects of adverse early attachment difficulties by establishing a secure bond between themselves and the client. Once this relationship is solidified, the therapist can help the client communicate more openly so they can eventually better understand how their current feelings and behaviors are associated with early childhood experiences (Costello, 2013; Costello, 2015).
That means that in ABT, it would be necessary for clients to explore their childhood in therapy. They may discuss their early relationship with their parent or caregiver, family dynamics as they grew up, and significant childhood experiences. Then, with their therapist’s help, they may see connections between their childhood, adult relationships, and their adult-child caregiver role, recognizing how the past may influence the present and how they regulate and cope (Costello, 2013; Costello, 2015; Goldstein, 2022).
The population of concern, in this case, is adult-child caregivers for individuals with Alzheimer’s or Related Dementia. ABT would involve the therapist and the adult-child caregiver. As previously stated, it has been shown that adult-child caregivers experience higher levels of burden than spousal caregivers despite spending less time in the caregiver role (Reed et al., 2014). Moreover, grief and high caregiver burden are positively correlated with the development of an AUD (Rachamim et al., 2021; Rospenda et al., 2010). Therefore, adult-child caregivers have been identified as the specific population at risk for this review and application.
Adult-child caregivers of individuals with Alzheimer’s or Related Dementia can be referred for services by their primary care physician (PCP) or by the PCP of their care recipient. The PCPs or Medical Assistants (MA) can administer the AUDIT-C to the caregiver. If they meet the criteria, they can be referred to a behavioral health provider/therapist for attachment-based therapy. The adult-child caregiver could have individual ABT in the hospital setting. If they provide transportation, they could meet for ABT in the hospital while their care recipient has their health care check-up. Alternatively, the adult-child caregiver can have ABT through Telehealth for accessibility and convenience.
There has been growing research on attachment-oriented treatment approaches for individuals with substance use disorders. Through the lens of attachment theory, substance abuse can be understood as “self-medication” and as an attempt to compensate for lacking attachment strategies (Schindler, 2019). It was discussed before how insecure attachment can be a pathway to maladaptive coping skills like alcohol and substance use. A systematic analysis across 34 cross-sectional studies and three longitudinal studies also supported the link between insecure attachment and substance use (Schindler, 2019). The research highlights the relevance of exploring attachment to understand and treat substance use-related issues.
7. Conclusion
While ABT has not previously been applied to this population, there is a strong potential for it to be utilized within this population and situation. As previously noted, MI and CBT are both dominant treatment modalities known to be effective short-term behavioral treatments for alcohol use disorders (Fletcher et al., 2014). With that being said, the high relapse prevalence should not be ignored (Recovery Village, 2022). After recognizing some of the limitations of CBT and MI (Hogden et al., 2012; NHS, 2019), it is now essential to begin exploring more attachment-based theories since attachment acknowledges the implications of childhood, interpersonal relationships, emotional processing, and communication as it pertains to behavior and changing behavior (Johnson, 2019).
The beauty of the ABT treatment modality is that it could be used as an active and preventative measure against AUD. The Treatment works towards building interpersonal problem-solving ability, and emotional regulation, which anyone going through grief and experiencing a high caregiver burden could benefit from (Costello, 2013; Costello, 2015; Goldstein, 2022), while MI and CBT function on the premise that the substance problem already exists (Lundahl & Burke, 2009; NHS, 2019).
Limitations of the ABT treatment modality would be for more serious AUD, the ABT treatment would not rapidly address it (Goldstein, 2022). For more serious AUD cases or for individuals with more severe mental health needs, practical and short-term symptom-focused treatment modalities like CBT and MI might be more beneficial for the safety and well-being of the client (Lundahl & Burke, 2009; NHS, 2019).