Addiction (1993) 88, 1405-1411

RESEARCH REPORT

Attachment among adult children of alcoholics

NADY EL-GUEBALY, MALCOLM WEST, ELEANOR

MATICKA-TYNDALE, & MARY POOL
Foothills Hospital, Calgary, Alberta, Canada

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

Introduction higher incidence of various fortns of emotional

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

1405
1406 Nady El-Guebaly et al.

clarify the nature of the relationship problems of been given special pressure for continuity
ACOAs should explore the potential value of through having been validated by both subse-
attachment theory. A recent study by Brennan, quent attachment events in the family and
Shaver & Tobey (1991) confirmed the special experiences within other relationships (i.e. the
importance of the attachment construct to the degree of success in havitig attachment needs
tmderstanding of the relationship problems of met). Thus successive relationship experiences
ACOAs. Undergraduate college students who interact with prior experiences, through the rep-
reported parental problem drinking scored high resentational model, to determine the
on both avoidant and anxious-ambivalent attach- individual's current state of mind with regard to
ment pattems. attachment.
TTiis paper furthers Brennan et al.'i explo- In the instance of ACOA individuals, contin-
ration of the relationship between attachment ued lack of success in achieving felt security
and ACOA status using an outpatient psychiatric reitiforces their pessimistic beliefs about attach-
population. It reports the results of an empirical ment. Because of their strength, these affectively
study which investigated the distinctive attach- charged beliefs about attachment exist as a
ment profile of ACOAs as compared to potential awaiting expression in current
ACONAs. relationships. In sum, the attachment experi-
ences of the past and the content of present
attachment relationships are formulated and
Attachment and parental alcoholism interpreted in terms of the ACOA individual's
Although most attachment research has con- representational model of attachment.
centrated on child-parent relationships, all One direct manifestation of the effect of these
attachment theorists acknowledge attachment to models is the defensive organization of attach-
he an important feature of adult relationships ment into panems of relating. Although
(Henderson, 1977; Weiss, 1982; Ainsworth, variously named, insecure attachment pattems
1989). Further—and critically—the function of across the life span move from the distant, de-
attachment remains unchanged from childhood tached to the close, enmeshed. In adults, Bowlby
to adulthood; that is, proximity to a special and (1977) has described three pattems of insecure
preferred other is sought or maintained in the attachment: anxious attachment, compulsive
expectation of finding security (Sheldon & West, self-reliance and compulsive care-giving. He has
1989). The sense of security in any attachment also referred to a balance between anxious and
relationship depends upon the quality of respon- angry attachment from which an ambivalent pat-
siveness experienced with that partner. tem appears to arise.
From this standpoint, the interpersonal prob- This study explored the relevance of the
lems of the ACOA may refiect adaptations to attachment construct to understanding the
and ways of dealing with a troubled familial long-term impact of alcoholism on children of
envirotiment leamed over many years alcoholics. Three hypotheses were tested.
(O'Cotinor, Sigman & Brill, 1987). Further, the Hypothesis 1: ACOAs and ACONAs score dif-
severity of the ACOA individual's interpersonal ferently on measures of attachment.
problems may reflect the rigidity and pervasive- Hypothesis 2: ACOAs demonstrate more dys-
ness of the relational difficulties within the family functional attachment styles than ACONAs.
across the span of years from childhood through Hypothesis 3: Severity of itnpact of parental
adolescence to adulthood. Long-continued and alcoholism on children is associated with severity
multiple stresses such as the inability of the of dysfunction in attachment.
alcoholic parent to respond empathetically, par-
entification of the child or repeated threats of
abandonment may lead to long-term relational Methods
difficulties. Selection of participants
These deficits and failures of the alcoholic This study was a cross sectional comparison of
parent's responsiveness are the data used by the adult children of alcoholics (ACOAs,n = 102)
child to create a representational model of self in and adult children of non-alcoholics
relation to others. Those representational models (ACONAs,n = 101). The target population con-
which are carried forward to adulthood have sisted of individuals between the ages of 21 and
 Attachment among adtilt children of alcoholics
65, seeking any one of a variety of short-term
therapeutic services of a hospital based outpa-
tient psychiatric program (n = 118) or a
community based alcoholism treatment program
(n = 85). All such services are available without
payment of a fee as part of Canada's universal
health and social service system.
Potential participants were approached at the
hospital or treatment centre. The study vsras ex-
plained and informed, written consent was
obtained prior to proceeding. Individuals with
significant physical illness, intellectual impair-
ment, or active psychoses were excluded from
the study. Eighty percent of those approached
met study criteria, agreed to participate, and
completed the research instruments described
below in one or two sessions separated by less
than two weeks. Recruitment spanned a period
of 18 months. Clinical responsibility for all par-
ticipants remained with the clinical stafF of the
respective programs.
Sample profile
The sample of 203 consisted of 93 (46%) men
and 110 women. The mean age for both genders
was 36.6 years, mean education 14 years and
mean Blishen occupational ranks (Blishen &
McRoberts, 1976) 39.8 for men and 39.2 for
women. TTiese occupational ranks indicate lower
middle and upper working class occupations re-
quiring 12-15 years education. Fifty-one percent
of those sampled were ACOAs. Sixty percent of
the men and 37% of the women were substance
abusers. Chi-square and t-tests showed that
ACOAs and ACONAs did not differ significantly
in sex, age, education, occupation, marital status
or substance abuse.
Scores on the Millon Clinical Multiaxia! In-
ventory (MCMI), a clinical assessment
instrument described in the measurement sec-
tion, produced profiles consistent with those of a
help-seeking population. The most prevalent dis-
orders were dysthymia and anxiety. Analysis of
covariance of the MCMI scores revealed no
significant differences in disorders related to sex,
age or occupation. Psychopathology, as mea-
sured by the MCMI, was not significantly
associated with ACOA/ACONA status.
Measurements
(I) The Reciprocal Attachment Questionnaire
(RAQ; West, Sheldon & Reiffer, 1987; West &
1407
Sheldon, 1988; West & Sheldon-Keller, 1992)
was used to assess the component features of
attachment in adults, that is, their style of anach-
ment to a peer. Drawing on the work of Bowlby
(1977), Ainsworth (1989), and Weiss (1982),
West et al. operationalized the key components
of reciprocal attachment as self-report scales. In
the RAQ, an attachment figure is defined as a
peer who is not a member of the family of origin,
with whom there is usually a sexual relationship
and with whom there has been a special relation-
ship for at least 6 months. Instructions to
respondents include a description of an attach-
ment figure as "the person you would be most
likely to tum to for comfort, help, advice, love or
understanding; the person you'd be most likely
to depend on, and who may depend on you for
some things; the person you feel closest to right
now."
Four subscales (separation protest, feared loss,
proximity seeking, and reciprocity) relate to the
criteria of attachment and serve to distinguish
adult attachment from other social relationships.
Two subscales (use of the attachment figure and
perceived availability of the figure) relate to the
unique provisions offered by attachment. Finally,
four scales assess the four identified pattems
of dysfunctional attachment relationships for
adult: compulsive self reliance, compulsive care-
seeking, compulsive care-giving and angry
withdrawal. The pattems, criteria and provisions
are further defined in Table 1.
The RAQ consists of 46-items each rated on a
5-point likert-type scale. Summation scores for
ten separate scales are produced. Six scales of
three items each relate to the unique criteria and
provisions of reciprocal anachment relationships,
with scores varying from 3 to 15. Four scales of
7 items each relate to dysfianctional pattems of
reciprocal attachment, with scores varying from
7 to 35.
As reported in detail in earlier publications
(West et d., 1987; West & Sheldon, 1988; West
& Sheldon-Keller, 1992), the validity and reli-
ability of the RAQ has been established with
clinical and non-clinical adult populations.
Across these sets of subjects, coefficient alpha
ranged from 0.74 to 0.85 indicating acceptable
structural coherence of the scales. Test-retest
reliability (over a 4 month period) with a com-
munity sample ranged from 0.76 to 0.82 for the
scales indicating their temporal stability. Factor
analysis confirmed the theoretical distinction
1408 Nady El-Guebaly et al.
Table 1. Definitions of attachment pattems and dimensions

Attachment items Definitions

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

between the criteria and provisions of adult of 0.98 is reported in the test manual Qones,
anachment and the differentiation of the attach- 1983). Validity of the CAST has been demon-
ment pattern scales into avoidant and enmeshed strated with an adult psychiatric population
categories. Finally, a discriminant functions (Staley & el-Gueba!y, 1991) and in comparisons
analysis demonstrated the scales were highly rel- of alternatively diagnosed and matched controls
evant to the differentiation of psychiatric of children Qones, 1983). The CAST was used
outpatients from non-patients. in this study to both identify ACOAs and
For the sample in this study, Cronbach alphas ACONAs and as an indicator of severity of im-
ranged from a low of 0.61 on the 7-item compul- pact of parental alcoholism on study participants
sive care-giving subscale to a high of 0.82 on the for those who were classified as ACOAs. In the
3-item feared loss subscale. Scores on all sub- former case, ACOAs were identified by scores of
scales approximated normal distributions. 6 or higher, ACONAs by scores of 0, and those
with scores of 1-5 were considered to have an
(2) The Children of Alcoholics Screening Test imcertain status and excluded from analysis (8
(CAST; Jones, 1983) is a widely used instrument individuals were in this category). For ACOAs,
for identifying adults who have at least one alco- the full CAST score was used as an indicator of
holic parent and for assessing the severity and severity of impact.
areas of impact of parental alcoholism on the In this study, a Cronbach alpha of 0.98 was
individual. It contains 30 yes/no items. Respon- obtained for the CAST items. CAST scores of
dents who self-identify at least six items as ACOAs deviated from a normal distribution,
characteristic of their parental home are desig- however, necessitating the use of the non-para-
nated as adxilt children of alcoholics (ACOAs). A metric Spearman rho correlation in measuring
Spearman-Brown split-half reliability coefBcient the association with RAQ scores.
 Attachment among adult children of alcoholics
(3) The Millon Clinical Multiaxial Inventory
(MCMI; Millon, 1987) is a 175 item, true-false
inventory that follows the multiaxial format em-
ployed in the DSM-III. Eleven personality
disorders, nine clinical syndromes, and one
validity scale are provided. The MCMI scales
were constructed and validated to measure
DSM-IIi typologies (Dana & Cantrell, 1988).
An issue, however, is the relative lack of
specificity reported in Volume II of the Millon
manual for the alcohol and drug subscales (Mil-
lon, 1987). The false positives and negatives are
34% and 44% respectively for the alcohol scale
and 37% and 48% respectively for the drug
scale. Consequently, substance abuse was mea-
sured using twelve items from these two scales
which matched with DSM-III-R criteria for sub-
stance abuse. The twelve items were subjected to
tests of face validity, discriminate validity, and
internal reliability. In the first instance, the con-
gruence of the items and DSM-III-R criteria for
substance abuse was assessed by experienced
clinicians. In the second, the ability of the twelve
item scale to discriminate between knovm sub-
stance abusers and non-abusers was assessed.
Finally, a Cronbach alpha of 0.89 demonstrated
an acceptable level of internal reliability of the
twelve-item tneasure.
Statistical analyses
Data were analyzed separately for males and
females. Substance abuse was entered into data
analysis as a control to test and measure its
impaa on relationship pattems, distinct from
that of ACOA status. T-tests, analyses of vari-
ance, chi-square contingency tables and
correlation analyses were used to assess the rela-
tionships between attachment, ACOA status,
severity of impact of parental drinking, and sub-
stance abuse. A Bonferroni correction was used
to protect against chance effects in multiple test-
ing, setting the p value at 0.05.
Results
Presence and characteristics of attachment figure
Twenty-eight percent (56) of those sampled did
not have an attachment figure. Chi-square tests
produced no significant associations between the
presence or absence of an attachment figure and
ACOA status, substance abuse or gender.
For 83% of the 147 participants who did have
an attachment figure, attachment was to a
1409
spouse (53%) or other sexual parmer (30%). An
additional 12% identified a same sex friend as an
attachment figure and 6% a relative other than
the spouse. Eighty percent reported the attach-
ment relationship was over a year's duration, the
longest having endured for 43 years. Chi-square
tests demonstrated no significant differences in
the characteristics of the attachment relation-
ships with respect to ACOA status, substance
abuse or gender.
ACOA status and attachment pattems and
dimensions
Table 2 presents results of comparisons of RAQ
scores for the 147 ACOAs and ACONAs with
attachment figures. For women, ACOAs and
ACONAs were significantly different in their
scores on angry withdrawal, separation protest,
use of the attachment figure, and perceived
availability of the attachment figure. No
significant associations were found for men.
Analyses of variance using both ACOA status
and substance abuse were conducted for males
and females separately to assess for possible in-
teractions between substance abuse and ACOA
status. Results indicated no significant difference
in RAQ scores for women based on whether they
were or were not substance abusers, nor any
interactions between substance abuse and
ACOA status. Only the association with ACOA
status was significant. For men, none of the
associations were significant.
Severity of impact of parental alcoholism and
attachment
Spearman rho correlations between CAST and
RAQ scores were calculated for male and female
ACOAs. Application of the Bonferroni correc-
tion required p-values at 0.005 or lower for
significance at the 0.05 level. Once the correc-
tion was applied, none of the correlations met
criteria for significance. Four of the correlations
for male ACOAs, however, approached
significance, suggesting further study with a
larger sample is warranted. These were the cor-
relations between CAST scores and compulsive
self reliance (rho = 0.32, p = 0.036), separation
protest (rho = 0.33, p = 0.031), lack of use of
attachment figure (rho = 0.30, p = 0.048), and
perceived lack of availability of attachment figure
(rho = 0.37,/! = 0.020).
1410 Nady Bl-Guebaly et al.

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

Male Female
RAQ ACONA ACOA t ACONA ACOA t

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

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

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