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Journal of Social Service Research, 1–12, 2014
c Taylor & Francis Group, LLC
Copyright ISSN: 0148-8376 print / 1540-7314 online
DOI: 10.1080/01488376.2014.896851
Attachment Style, Spirituality, and Depressive Symptoms
Among Individuals in Substance Abuse Treatment
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Naelys Diaz
E. Gail Horton
Tammy Malloy
ABSTRACT. Adult attachment styles and spirituality have been shown to be protective factors against
depressive symptoms among individuals in treatment for substance use disorders. However, no studies
to date have examined how these two factors simultaneously are related to depressive symptomatology
in this population. Thus, this study aimed to examine how adult attachment styles (secure vs. insecure
attachment styles) and 2 distinct spirituality dimensions (existential purpose and meaning in life and
religious well-being or the perceived relationship with God) are associated with depressive symptoms.
Using a cross-sectional design, 77 individuals receiving substance abuse treatment were asked to
complete a battery of self-report questionnaires. Hierarchical multiple regression analyses indicated that
secure attachment style and higher levels of existential purpose and meaning in life were significantly
related to lower levels of depressive symptoms whereby the existential purpose and meaning in life
was a stronger predictor of depressive symptoms. These results suggest that practitioners may consider
addressing attachment issues during treatment; however, emphasizing ways to increase individuals’
purpose and meaning in life may further enhance treatment outcomes. Future research should utilize
a larger sample size, include more comprehensive measures of attachment styles, and explore ways to
increase purpose and meaning in life in this population.
KEYWORDS. Depressive symptoms, attachment styles, spirituality, meaning in life, substance use
There is consensus within the literature that there
are high comorbidity rates between major depressive disorder and substance abuse disorder
(Brienza et al., 2000; Grant et al., 2004; Klein,
Schwartz, Rose, & Leader, 2000). Research has
shown that individuals diagnosed with alcohol
dependence are 4 times more likely to be diagnosed with a co-occurring depressive disorder
than those without alcohol dependence (Grant
et al., 2004). Furthermore, Regier et al. (1990)
in their Epidemiological Catchment Area survey
found the comorbidity of these disorders in the
general population to be more than twice as high
as would be expected by chance.
It is important to examine factors associated with depressive disorders among individuals with substance use disorders. Multiple negative effects have been reported among those in
Naelys Diaz, Ph.D., is an Associate Professor at Florida Atlantic University, School of Social Work, Boca
Raton, FL.
E. Gail Horton, Ph.D., is an Associate Professor at Florida Atlantic University, School of Social Work,
Boca Raton, FL.
Tammy Malloy is the Chief Clinical Officer at Behavioral Health of the Palm Beaches, North Palm Beach,
FL.
Address correspondence to: Naelys Diaz, Ph.D., Florida Atlantic University, School of Social Work, 777
Glades Road, Boca Raton, FL 33433 (E-mail: [email protected]).
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N. Diaz et al.
treatment for these comorbid conditions, including the presence of depressive symptoms preceding relapse (Miller, Westerberg, Harris, & Tonigan, 1996; Strowig, 2000) and greater severity
of substance use following relapse (Tate, Brown,
Unrod, & Ramo, 2004). In addition, higher rates
of high-risk injection use, continued drug use,
and drug relapse across different types of addictive substances have also been found (Marlatt
& Gordon, 1985; Stein, Solomon, Herman, Anderson, & Miller, 2003). Moreover, treatment
dropout rates and poorer prognosis after substance abuse treatment have been found among
individuals with comorbid depressive and substance use disorders (Rounsaville, Weisman,
Crits-Christoph, Wilber, & Kleber, 1982).
Recent research concerning depression among individuals with substance abuse issues has
focused on the protective value of spirituality.
For example, spirituality has been shown to be
an essential component of positive treatment
outcomes and recovery for substance use
disorders (Chen, 2006; Jarusiewics, 2000). In
addition, it has been related to abstinence during
or after treatment (Jarusiewics, 2000) and has
been described as “a powerful antagonist of
addiction” (Unterrainer, Huber, Stelzer, & Fink,
2012, p. 68).
In a recent study, Diaz, Horton, McIlveen,
Weiner, and Williams (2011) explored the relationships among depressive symptomatology,
spirituality, and several religious factors (the respondents’ perceived relationship or closeness
to God, religious background/practices, and respondents’ image of God). Results indicated that
the religious background/practices and respondents’ image of God were not significantly associated with levels of depressive symptoms.
However, respondents’ perceived closeness to
God was positively related to depressive symptoms, and spirituality was inversely related to
depressive symptoms. Of the three spirituality
measures employed in the study, the score on
the Spiritual Well-Being Scale (SWB; Ellison,
1983) was the strongest predictor of depressive
symptomatology.
The SWB is composed of two subscales: Existential Well-Being (EWB; feelings of transcendental purpose and meaning) and Religious Well-Being (RWB; feelings of closeness to
God). The researchers found that higher levels
of existential spirituality were related to lower
levels of depression as expected. However, they
found the surprising results that higher levels of
relational spirituality were related to higher levels of depressive symptoms. In explaining these
counterintuitive results, the researchers speculated that the findings concerning respondents’
feelings of relatedness to God may have been
largely explained by participants’ adult attachment style based on their ideas on work concerning attachment and spirituality by Granqvist
(2002). Granqvist’s emotional compensation hypothesis proposes that individuals with histories of insecure attachments use their religion
primarily to regulate their affect and to obtain
a sense of security deriving from a relationship with a supportive God. Thus, Diaz and her
colleagues (Diaz, Horton, McIlveen, Weiner, &
Williams, 2011) speculated that the positive relationship between levels of depressive symptoms
and levels of relatedness to God may have been
due to poor relationships in respondents’ everyday lives associated with adult attachment style,
not to their relationship with God.
A considerable amount of research has linked
depressive symptoms to adult attachment styles,
particularly insecure attachment styles (Fonagy
et al., 1996; McMahon, Barnett, Kowalenko,
& Tennant, 2006; Patrick, Hobson, Castle,
Howard, & Maughan, 1994; Rosenstein &
Horowitz, 1996). Attachment theory, developed
by Bowlby (1977, 1980, 1982), is a widely accepted theory that explains social and relational
aspects of individuals based on their interactions
with significant others. According to Bowlby
(1977), attachment behaviors are biologically
driven in an instinctual effort to maximize survivability, and children engage in proximityseeking behaviors with a primary caregiver. The
quality of the child–caregiver relationship is encoded into implicit memory that defines an internal working model of self (IWM). The IWM
determines children’s expectations for acceptance/rejection in future relationships throughout the life span.
Using Bowlby’s research on childhood attachment processes, Bartholomew and Horowitz
(1991) developed a four-category model of adult
attachment styles that includes secure style and
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Attachment, Spirituality, Depression
three insecure styles (preoccupied, dismissive,
and fearful). According to these authors, adults
with a secure attachment style are likely to have
a positive view of both self and other. These
individuals tend to have a strong sense of selfworthiness and to be willing to have emotional
connections with others. In comparison, individuals with a preoccupied attachment style are
likely to have a negative view of self and a positive view of others coming from feelings of low
self-worth and anxiety and fear concerning abandonment by others. They rely on acceptance by
others for their own acceptance of themselves
and frequently engage in attention-seeking behavior to maintain proximity to others. Individuals with a dismissive style are likely to have
a positive view of self and a negative view of
others; they tend to see themselves as having a
relatively high sense of self-worth but have little
trust in intimate relationships. Lastly, individuals
with a fearful style are likely to have a negative
view of both self and others. They tend to lack
a sense of personal worth and to have expectations of abandonment that interfere with their
development of healthy intimate relationships.
Research has shown that individuals with an
insecure attachment style are susceptible to depression due to their tendency to create negative
life events again and again that bolster a sense
of helplessness and hopelessness in what they
perceive as inescapable adversity (Bemporad &
Romano, 1992; Rholes & Simpson, 2004). Several studies have noted that the preoccupied adult
attachment style is associated with depressive
symptoms (Cole-Detke & Kobak, 1996; Eng,
Heimberg, Hart, Schneier, & Liebowitz, 2001;
Williams & Riskind, 2004). Others have noted
a relationship between an avoidant attachment
style and depression (Carnelley, Peitromonaco,
& Jaffe, 1994; Mickelson, Kessler, & Shaver,
1997). In addition, Flores (2003) has argued
that inadequate parental availability and/or responsiveness during infancy results in impaired
emotional regulation among individuals with
substance abuse disorders; these individuals attempt to repair the impaired emotional regulation by using substances that regulate their
emotions while reducing psychic pain and/or
providing distractive stimulation. He argues that
addiction is “both a consequence of and a solu-
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tion to the absence of satisfying relationships”
(Flores, 2003, p. 50) in the substance user’s life.
Even though attachment behaviors are
mainly manifested toward the primary caregiver
during infancy, individuals tend to form other
relationships in adulthood that become an
important part of their attachment hierarchy.
Some of these attachments include relationships
with a romantic partner, a close friend, a therapist, or even God/Higher Power (Kirkpatrick,
2005; Kirkpatrick & Shaver, 1992 Rowatt
& Kirkpatrick, 2002). Thus, there is a body
of knowledge that establishes the connection
between adult attachment and spirituality;
however, this literature focuses primarily on
religiosity and does not integrate purpose and
meaning in life as an important protective factor
against depressive symptoms, particularly
among individuals with substance use disorders.
Although this review of the literature
indicates that researchers have explored the
relationships between attachment styles and
depressive symptoms and between spirituality
and depressive symptoms, no studies have
yet examined these factors together to determine their relative importance as they relate
to depressive symptoms in this population.
Therefore, the current study was designed to
expand upon the existing knowledge base in
an effort to reduce this gap in the literature. It
was hypothesized first that adults with secure
attachment styles would have lower levels of depressive symptoms than would individuals with
insecure attachment styles. In regard to the two
spirituality dimensions, it was hypothesized that
higher levels of existential purpose and meaning
in life would be related to lower levels of
depressive symptoms. In addition, and based on
previous findings in the literature, higher levels
of religious well-being or perceived closeness
to God would be related to higher levels of
depressive symptoms. The findings from this
study could have clear implications for social
service providers who may consider the relative
importance of attachment styles and spirituality
to help them determine the focus of clinical
treatment for clients with comorbid depressive
and substance use disorders. Furthermore, the
results may provide useful information about
the protective quality of the two different
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N. Diaz et al.
dimensions of spirituality—purpose and meaning and the perceived relationship with God.
These are two distinct constructs that may contribute in different ways to clinical outcomes.
Thus, findings from this study may assist practitioners in tailoring treatment to better address the
specific needs of their dually diagnosed clients.
METHOD
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Participants
This study used a convenience sample of individuals attending a substance abuse treatment
center located in Florida. This is a for-profit
facility that provides detoxification services,
inpatient rehabilitation, residential, partial
hospitalization, and intensive outpatient and
outpatient services to self-pay and insurance-pay
clients; the majority of the clients pay through
their individual insurance. Attendance to this
center is voluntary. All clients recruited for this
study were receiving residential services. After
researchers received approval from the institutional review board, participants were recruited
from two different satellite sites of the treatment
center from September 2012 to December 2012.
Inclusion criteria included clients who were
18 years or older and those who had completed
the detoxification phase of treatment. Clients
were asked to fill out a questionnaire packet that
contained the informed consent during one of
their morning group meetings at the treatment
center. It took approximately 45 min to complete
all the self-reported questionnaires. All clients
who attended the meeting on the date the
questionnaires were administered participated
in the study. Seventy-seven clients volunteered
to participate in the study; 52 clients were
recruited from Site 1 and 25 were recruited from
Site 2. Participants did not receive monetary
incentives for their participation in this study.
Participants had a mean age of 31.66 years
(SD = 11.68). More than half of the respondents
were men (55.8%, n = 43), and the large majority (89.6%, n = 69) self-identified as White
Non-Hispanic. More than half of the participants
reported being single and never having been
married (53.2%, n = 41), while another 22.1%
(n = 17) reported being currently married,
10.4% (n = 8) reported being divorced, 5.2%
(n = 4) were separated, and 7.8% (n = 6) were
cohabitating with an unmarried partner. Fifty
percent of participants reported having full-time
employment (n = 38), while 17.1% (n = 13)
had part-time employment, 26.3% (n = 20)
were unemployed, 2.6% (n = 2) were retired,
and 3.9% (n = 3) were homemakers. In terms of
religious affiliation, most participants reported
being Catholic (44.2%, n = 34) or having no
religious affiliation (28.9%, n = 22), while
smaller proportions identified as Protestant
(7.8%, n = 6) and other (18.4%, n = 14). There
were no statistically significant differences
between participants attending the two sites on
any of the demographic variables, and thus, the
analyses were conducted on the entire sample
from the two sites. None of the demographic
variables were significantly correlated with
depressive symptoms.
Measures
The Spiritual Well-Being Scale
The SWB (Ellison, 1983) was used to assess
for spiritual well-being. The SWB is a 20-item
self-report scale that contains two subscales: a)
the EWB (“I don’t know who I am, where I came
from, or where I am going”); and b) the RWB (“I
have a personally meaningful relationship with
God”). The SWB has a 6-point Likert-type scale
that includes SA = strongly agree, MA = moderately agree, A = agree, D = disagree, MD
= moderately disagree, and SD = strongly disagree. These items were scored from 1 to 6, with
a higher number indicating more well-being, 1 =
SD, 2 = MD, 3 = D, 4 = A, 5 = MA, and 6 =
SA. It has demonstrated psychometric properties.
Coefficient alphas of .97 and a test–retest coefficient of .93 have been reported for the RWB,
while the EWB obtained .90 and .80, respectively (Saunders, Lucas, & Kuras, 2007). Cronbach’s alphas for this sample were .91, .94, and
.86 for the SWB, RWB, and EWB, respectively.
Relationship Questionnaire
The Relationship Questionnaire (RQ;
Bartholomew & Horowitz, 1991) uses both
categorical and continuous measurements of
attachment. In the categorical section, respondents identify one of four possible vignettes
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Attachment, Spirituality, Depression
(one for each adult attachment style—secure,
fearful, preoccupied, and dismissing) that best
describes their close relationships. Respondents
are then asked to indicate on a 7-point
Likert-type scale (1 = disagree strongly, 4 =
neutral/mixed, and 7 = agree strongly) how
accurately each vignette describes them. The
RQ attachment ratings show convergent validity
with adult attachment ratings (Bartholomew
& Horowitz, 1991). In addition, it has shown
moderately high stability during an 8-month
period (Scharfe & Bartholomew, 1998) and
has moderate test–retest reliability (Griffin &
Bartholomew, 1994). This instrument has been
utilized to measure attachment among individuals with alcohol abuse problems (McNally,
Palfai, Levine, & Moore, 2003) and has been
used in clinical populations (Dutton, Saunders,
Starzomski, & Bartholomew, 1994; Haaga et al.,
2002; Pistole & Tarrant, 1993).
The Center for Epidemiologic Studies
Depression Scale
The Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) was utilized to measure the current level of depressive symptomatology. The CES-D is a 20-item
self-report scale that has been used in multiple recent research studies with individuals who
abused substances (Diaz, Horton, Green, et al.,
2011; Diaz, Horton, McIlreen, et al., 2011; Larson et al., 2007; Sofuoglu, Poling, Gonzalez,
Gonsai, & Kosten, 2006; Strathdee et al., 2006).
Respondents are asked how often they experienced each symptom during the previous week
using a 4-point Likert-type scale. Response categories are as follows: 0 = rarely or none of the
time (less than 1 day), 1 = some or little of the
time (1–2 days), 2 = occasionally or a moderate amount of time (3–4 days), and 3 = most or
all of the time (5–7 days). The total score is the
sum of these 20 items and provides a continuous measure from 0 to 60. A cutoff score of 16
or more categorizes the respondent as clinically
depressed (Myers & Weissman, 1980; Schulberg
et al., 1985). The CES-D has demonstrated high
reliability in a variety of clinical and community
samples (Orme, Reis, & Herz, 1986; Radloff,
1977, 1987). In a substance abuse sample, the
internal consistency reliability was reported to
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be .81 for the total scale (Diaz, Horton, Green,
et al., 2011). In this sample, the Cronbach’s alpha was .92.
Other Variables
Demographic information was collected by
self-report and included age and gender (female
or male). Respondents also self-identified their
race/ethnicity as White Non-Hispanic, Hispanic,
African American, or Other. Response categories for marital status included single, never
married, legally married, cohabitating with partner (but not married), separated but still married,
divorced, widowed, and other (specify). Respondents were asked to identify their religious affiliation: Catholic, Adventist, Jehovah’s Witness,
Mormon, Jewish, Muslim, Buddhist, Protestant,
other, and none. In addition, respondents were
asked to identify their employment status as either: work 40 hr per week, work fewer than 40 hr
per week, homemaker, retired, or unemployed.
Data Analyses
An alpha level of .05 was used to assess statistical significance. Frequencies were examined to
determine the numbers of participants in each of
the four adult attachment styles (secure, preoccupied, dismissing, and fearful). Because there
were only four participants in the dismissing
group, the variable was transformed into a dichotomous variable containing a secure group
(0) and an insecure group (1). The depression
variable was also dichotomized so that comparisons between those who had clinical levels
of depression (0) and those who scored below
the clinical-level cutoff (1) could be made. Relationships between these categorical variables
were then analyzed using two-way contingency
analysis of depression (clinical and nonclinical) and attachment style (secure and insecure).
Pearson’s r correlations were conducted to assess for the relationship and strength between the
spirituality variables, attachment styles, and depressive symptoms. In all of these analyses, the
number of respondents in some analyses varied
due to missing data.
Hierarchical multiple regression analyses
were used to determine the relative effect of each
independent variable on depressive symptoms.
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N. Diaz et al.
For these analyses, the continuous values of the
depression variable were utilized. Three models
were built entering: a) the attachment style variable (RQ); b) the RWB variable and RQ; and
c) the RWB, the RQ, and the EWB. R-square
changes were calculated with each new equation.
The order of variables entered into the model was
based on theoretical understanding that attachment style is established very early in life and before a spiritual understanding can be developed.
RESULTS
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Univariate Analyses
Of the 77 participants in the study, 91% (n =
70) completed the RQ. Frequency analyses indicated that there were 26 participants (37.1%)
who reported a secure style, 27 (38.6%) who
reported a fearful attachment style, 13 (18.6%)
who reported a preoccupied style, and 4 (5.6%)
who reported a dismissing style. Because of
the low number of participants reporting a dismissing style, this variable was collapsed into
a dichotomous variable containing 44 participants (62.6%) reporting an insecure style and 26
(37.1%) reporting a secure style.
Of the 77 participants, 68 (88.3%) completed
the CES-D. Out of the 68, more than half
(63.2%, n = 43) reported CES-D scores of 16
or higher indicating high levels of depressive
symptoms.
Bivariate Analyses
Correlation analyses indicated that all
variables (SWB, EWB, RWB, and RQ) were
statistically significantly related to depressive
symptoms (see Table 1). All three of the
spirituality scales were negatively related to depressive symptoms; the EWB had the strongest
relationship with depressive symptoms.
The chi-square tests indicated that depressive
symptoms were significantly associated with attachment style, X 2(1, 70) = 10.06, p = .002
(see Table 2). Approximately 80% (n = 35) of
respondents who reported an insecure style reported clinical levels of depressive symptoms
compared with only 42% (n = 11) of the secure
attached individuals.
Multivariate Analyses
Table 3 presents the results of the hierarchical
multiple linear regression models that examined
potential factors associated with continuous depressive symptomatology. The model included
the two attachment styles (secure vs. insecure)
and the two subscales of the SWB. In the first
equation, the attachment variable (RQ) was a
statistically significant predictor of depressive
symptoms (p < .01), with the insecure attachment style being associated with higher levels
of depressive symptoms. This model accounted
for 14.1% of the variance in depression scores.
When the relational spirituality subscale (RWB)
was added in the second equation, it was not
significantly related to depressive symptoms. In
this equation, the attachment variable remained
highly significant (p < .01). In the final equation when the existential spirituality subscale
(EWB) was entered, neither the RQ (attachment
style) nor the RWB remained significant. However, the EWB was a highly significant predictor
of depressive symptoms (p < .001), with higher
scores on the EWB associated with lower levels
of depressive symptoms. In addition, this variable accounted for an additional 24.2% of the
variance in depressive symptom level for a total
of 41.6%.
DISCUSSION
The purpose of this study was to examine
how two factors—attachment styles and two dimensions of spirituality—were related to depressive symptoms in a sample of individuals in
residential treatment for substance abuse issues.
The high comorbidity rates between depressive
symptoms and substance abuse disorders have
been extensively documented in the literature
(Brienza et al., 2000; Grant et al., 2004; Klein
et al., 2000; Regier et al., 1990), and the findings of this study are generally consistent with
that literature in that approximately 63% of the
substance abuse treatment sample reported clinical levels of depressive symptoms. Interestingly,
63% of the respondents also reported an insecure attachment style. This finding is not surprising because substance abuse disorders are
Attachment, Spirituality, Depression
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TABLE 1. Pearson’s Product–Moment Correlations for Depression Scores (CES) With Overall
(SWB), Existential (EWB), and Relational (RWB) Spirituality Scores and Attachment Style (RQ)
CES
Pearson’s Correlation
N
SWB
Pearson’s Correlation
N
EWB
Pearson’s Correlation
N
RWB
Pearson’s Correlation
N
RQ
Pearson’s Correlation
N
CES
SWB
EWB
RWB
RQ
1
68
−.452∗∗∗
68
−.616∗∗∗
68
−.249∗
68
.299∗
63
1
76
.832∗∗∗
76
.917∗∗∗
76
−.279∗
69
1
76
.549∗∗∗
76
−.352∗∗
69
1
−.191
70
1
70
∗
p < .05. ∗ ∗ p < .01. ∗∗∗ p < .001.
CES = Center for Epidemiologic Studies Depression Scale; SWB = Spiritual Well-Being Scale; EWB = Existential Well-Being Scale; RWB
= Religious Well-Being Scale; RQ = Relationship Questionnaire.
more likely among individuals with anxious attachment styles (Riggs et al., 2007). In addition,
results in the current study are congruent with
the literature showing that the fearful attachment
style predominates among individuals with drug
dependence (Schindler et al., 2005). Also consistent with previous research showing that individuals with a dismissing attachment style are the
least likely to enter treatment (Caspers, Yucuis,
Troutman, & Spinks, 2006), only a very small
proportion of participants in this study (5.6%)
reported a dismissing style.
Our first hypothesis that participants reporting a secure adult attachment style would have
lower levels of depressive symptoms compared
with those reporting insecure styles was supported. Almost 80% of participants who reported an insecure attachment style also reported
clinical levels of depressive symptoms. In comparison, only 42% of those reporting secure attachment scored above the clinical cutoff point
for depressive symptoms. This finding is consistent with the literature that indicates associations
between insecure attachment and psychopathology, particularly depression (Biffulco, Moran,
Ball, & Bernazzani, 2002; Gerlsma & Luteijn,
2000).
Based on previous studies (Daaleman &
Kaufman, 2006; Diaz, Horton, McIlveen, et al.,
2011; Kendler et al., 2003), it was expected
that spirituality would be related to depression
scores such that higher levels of existential
purpose and meaning in life would be related to
lower levels of depression and higher religious
well-being, or perceptions of closeness to God
would be related to higher levels of depressive
TABLE 2. Crosstabulation of Level of Depression and Attachment Style
Attachment Style
Depression Level
Insecure % (n)
Secure % (n)
Total % (n)
Nonclinical
Clinical
20.5 (9)
79.5 (35)
57.5 (15)
42.3 (11)
34.3 (24)
65.7 (46)
∗∗
p < .01.
X 2(df)
10.06 (1)∗∗
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N. Diaz et al.
TABLE 3. Summary of Hierarchical Multiple Regression Analysis Regressing Depressive
Symptoms on Attachment Style and the Spirituality Subscales
Unstandardized Regression Coefficient
Variable
Attachment style
SWB Relational
SWB Existential
R2
R 2 Change
F
Eq. 1
Eq. 2
Eq. 3
9.58∗∗
8.37∗∗
−.179
.141
.174
.032
6.30∗∗
0.824
.129
−.824∗∗∗
.416
.242∗∗∗
14.00∗∗∗
10.05∗∗
p < .01. ∗∗∗ p < .001.
SWB = Spiritual Well-Being Scale.
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∗∗
symptoms. Only the first hypothesis was
supported. Participants who reported higher
scores on the EWB were more likely to report
lower levels of depressive symptoms. These
findings are not surprising because the existential dimension of spirituality involves purpose
and meaning in life (Diarmuid, 1994), possibly
resulting in feelings of hope and optimism and
thus buffering symptoms of depression.
Counter to our expectations, however, there
was a nonsignificant relationship between the
relational dimension of spirituality or perceived
relationship with God (the RWB) and depressive symptoms. This finding is not consistent
with results from two previous research studies conducted in a substance use population
(Diaz, Horton, Green, et al., 2011; Diaz, Horton,
McIlveen, et al., 2011) that indicated a positive relationship between these variables. A confounding factor and possible explanation for this
contradictory finding could involve the recent
implementation of a religious track at the treatment center while this research study was being
conducted. Based on empirical evidence in the
literature documenting the negative relationship
between spirituality and depression, the treatment center implemented this track and clients
attended sessions where topics related to their
religious beliefs and practices and their addiction were the focus of clinical attention. Thus,
it is possible that the religious track might have
modified clients’ perceptions about their relationship with a transcendent being and the role
that the relationship plays in their lives, resulting in a larger number of participants without
clinical levels of depression reporting a stronger
relationship with God, thus affecting the results
of this study.
Results of the hierarchical multiple regression
analyses indicated that when attachment style
and the relational/religious well-being dimension of spirituality were examined together, attachment style was the only factor significantly
related to level of depressive symptoms. This
result is interesting because it suggests that attachment style is more important than their perceived closeness to God in predicting depressive
symptoms in this sample.
Interestingly, neither religious well-being nor
attachment style was associated with depressive
symptoms after the existential dimension was
added to the model. This finding suggests that
although individuals’ current relationships may
not be ideal because of attachment issues, if they
have adequate levels of existential purpose and
meaning in life, they may be protected against
clinical levels of depressive symptoms. Very
little research has been conducted concerning
relationships between purpose and meaning
in life and substance abuse. However, these
findings are consonant with early research that
showed that drug users scored significantly
lower on measures of purpose and meaning of
life than did individuals who did not use drugs
(Shean & Fetchman, 1971) and that individuals in residential treatment for drug abuse had
significantly lower levels of meaning in life compared with non-drug-using controls (Nicholson
et al., 1994). More current research concerning
relationships with meaning in life among
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Attachment, Spirituality, Depression
adolescents revealed that lower levels of meaning in life were correlated to illegal drug use and
sedative use among male adolescents and binge
drinking among female adolescents (Brassai,
Piko, & Steger, 2011). In addition, Mascaro
and Rosen (2008) showed that low levels of
meaning in life are related to increases in depression during a 2-month period among college
students.
There are various limitations in the present
study. First, generalizability is limited because
the sample used for this study came from a single
residential treatment agency located in Southeastern Florida. The racial and ethnic composition of the sample also compromises generalizability as the vast majority of clients were
White Non-Hispanics. In addition, it is important to mention a measurement concern in that
the categorical nature of the RQ (Bartholomew
& Horowitz, 1991) did not allow for a thorough
examination of the continuous dimensions of attachment styles. It would be valuable for future
investigations to utilize a more comprehensive
instrument such as the Experiences of Close
Relationship Scale (Fraley, Waller, & Brennen,
2000), which could expand on the relationship
of the examined variables. Moreover, this study
did not include a control group of a different clinical sample or nonclinical participants,
and thus, it is not possible to make comparisons with higher-functioning groups. Lastly,
this study involved a very small number of
respondents reporting a dismissing attachment
style, which limited the confidence in the findings concerning this particular attachment category. Dismissing clients are the least likely to
seek treatment among all the insecure attached
individuals; therefore, future investigations will
need to recruit a larger sample that would allow a sufficient number of respondents per
category.
Despite these limitations, this study is the first
to examine depressive symptomatology, attachment style, and spirituality among individuals
with substance abuse problems in a residential
treatment facility. Therefore, this study fills an
important gap in the knowledge base concerning risk and protective factors that influence this
population.
9
Conclusion and Implications for Practice
and Future Directions
Previous studies examining attachment styles
and spirituality have not been conducted among
individuals struggling with substance abuse
issues and have been limited to exploring how attachment styles and spirituality separately influence depression. Our study expanded the existing literature by examining the relative influence
of these two factors simultaneously on depressive symptoms in this population. In addition,
previous investigations have focused on a single dimension of spirituality, religiosity, while
our study explored two dimensions—existential
purpose and meaning in life and religious wellbeing or the perceived relationship with God.
The inclusion of two dimensions may enhance
our understanding of the potential protective role
that purpose and meaning in life may bring to
dually diagnosed individuals.
Based on our findings, having an insecure attachment style seems to be a risk factor for the
development of depressive symptoms. Another
significant finding of this study shows that the
existential-purpose and meaning-in-life dimension of spirituality seems to be the most important factor related to depressive symptoms
among this sample of individuals in treatment
for substance abuse issues. Although our results
suggest that practitioners could consider focusing on promoting improved interpersonal relationships for individuals with insecure attachment styles, they may want to place the fostering
of purpose and meaning in life as a higher priority for treatment planning. These results may
also have implications for program development.
First, many substance abuse treatment programs
are based on the 12-step model that stresses
the spiritual component of addiction. Therefore,
these programs might take into consideration the
relative importance of the two spiritual dimensions and put into place programmatic support
for the development of purpose and meaning in
life rather than stressing the perceived closeness
to God.
Future research may expand our results by exploring the insecure attachment styles in greater
depth. This exploration could include a larger
Downloaded by [Naelys Diaz] at 07:16 23 April 2014
10
N. Diaz et al.
sample that would allow analyses of the dismissing style, which was not possible in our study
due to the low number of individuals in this
category. Likewise, future investigations may
consider having a more diverse sample to examine the impact of demographic factors (e.g.,
race/ethnicity, culture, religious affiliation, and
practices) on the results. In addition, it would
be interesting to use an instrument that assesses
for levels of attachment anxiety and avoidance
rather than categorical attachment styles.
Lastly, considering the relative importance
of the purpose and meaning in life, future research may focus on ways that practitioners
can help their clients to increase purpose and
meaning within a therapeutic environment. It
would be interesting to understand clinical techniques, methods, and/or activities that would foster this dimension of spirituality. For example,
therapeutic activities that involve creativity (i.e.,
painting, drawing, writing, dancing, gardening,
etc.), solitude (i.e., praying, meditation, walking a labyrinth, etc.), and service to others (i.e.,
service and chores within a residential program,
service to the larger community where the facilities are located) could be explored in future
research.
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