Attachment and Substance Use Disorder: An Interventional Study in an Addictology Day Hospital

Centre Hospitalier de Cadillac48 enrolled

Overview

Introduction: Substance use disorders represent a major public health issue due to their high morbidity and mortality rates. Outpatient care, particularly short-term intensive programs integrating multidisciplinary support and craving management workshops, has demonstrated greater effectiveness than inpatient hospitalization in terms of abstinence, reduction in substance use, and improvement in quality of life (McCarty et al., 2014; Trebalag et al., 2018; Chirokoff et al., 2023). In parallel, the literature suggests a robust association between insecure or disorganized attachment styles and increased vulnerability to the development of addictive disorders (Branstetter et al., 2009; Danielsson et al., 2011; Zhai et al., 2014). Objective: The primary objective of this study is to evaluate the effectiveness of a 7-week attachment-focused therapeutic program in reducing the severity of substance use disorder among adults with insecure or disorganized attachment styles receiving treatment in an addictology day hospital. Method: Through a randomized controlled study, the present research compares two groups: an experimental group receiving a 7-week attachment-focused program (one individual session per week, followed by two hours of weekly group workshops) and a control group receiving the standard care protocol of the addictology day hospital (one 3-hour workshop per week for 7 weeks). Expected outcomes: The findings of this study are expected to demonstrate the relevance of attachment-focused interventions in the treatment of substance use disorders. This research aims to improve addiction care by integrating relational and emotional dimensions into treatment. Finally, it may contribute to the evolution of clinical practices toward a more relationship-centered approach, with anticipated benefits in terms of treatment retention, relapse reduction, and overall healthcare system efficiency.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

NONE

Enrollment

Interventions

attachment-focused therapeutic programBEHAVIORAL

The attachment-focused therapeutic program evaluated in this study was delivered over a 7-week period. The intervention comprised six weekly group sessions (Weeks 1-6), facilitated by a co-therapy team consisting of a psychiatry/addiction medicine resident and either an addiction nurse or an addiction psychologist. In addition, participants received seven weekly individual sessions (Weeks 1-7), each conducted by a psychiatry/addiction medicine resident.

psychoeducation-based intervention (standard care)BEHAVIORAL

The psychoeducation-focused therapeutic program targeting addictive disorders was also delivered over a 7-week period. The intervention included six weekly group sessions (Weeks 1-6), facilitated by a co-therapy team consisting of either two addiction nurses or one addiction nurse and one addiction psychologist. In addition, participants received seven weekly individual sessions (Weeks 1-7), each conducted by an addiction nurse.

Eligibility

Sex: ALLMin age: 18 YearsMax age: 65 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Aged 18 to 65 years * Enrolled in a care program at the Addictology Day Hospital of Cadillac Hospital * Exhibiting an insecure or disorganized attachment style * Diagnosed with a substance use disorder according to DSM-5 criteria * Provided informed consent and signed the consent form Exclusion Criteria: * Presence of severe cognitive impairments that prevent completion of questionnaires * Presence of decompensated acute psychiatric disorders (e.g., schizophrenia, manic episode) * Currently receiving psychotherapeutic treatment * Previous participation in attachment-focused interventions (e.g., Lifespan Integration, schema therapy) * Being pregnant or breastfeeding * Under legal protection (guardianship, conservatorship, or similar)

Outcomes

Primary Outcomes

Composite craving score obtained with a Visual Analog Scale (VAS)

In response to the primary outcome criterion, a composite craving score will be assessed during the experimental and follow-up phases. This score is calculated by the investigator at the end of each follow-up visit and is derived from the participant's self-assessment, completed using a patient diary filled out at home. In this diary, participants record each craving episode and rate its intensity using a Visual Analog Scale (VAS) ranging from 0 (no craving) to 10 (intense craving). This VAS has been widely used in craving-related research (Badredine, 2021; Trojak \& Demina, 2025).

Time frame: Experimental phase: 7 weeks (equivalent to 1 therapeutic cycle) Follow-up phase: 3 months

Secondary Outcomes

Experiences in Close Relationships - Relationship Structures (ECR-RS) (Fraley et al., 2011)

The Experiences in Close Relationships - Relationship Structures (ECR-RS) (Fraley et al., 2011) is a self-report questionnaire that assesses attachment style across different types of close relationships (parents, friends, and romantic partners). It consists of 9 items rated on a 7-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). The ECR-RS measures two main dimensions of attachment: anxiety (fear of rejection or abandonment) and avoidance (tendency to avoid intimacy or emotional dependence). High scores on either dimension indicate insecure attachment. The instrument has good psychometric properties, and a French validation was conducted by Lafontaine et al. (2016).

Time frame: The ECR-RS will be administered once, prior to the start of the intervention.

Childhood Trauma Questionnaire (CTQ) (Bernstein et al., 1994)

The Childhood Trauma Questionnaire (CTQ) (Bernstein et al., 1994) is a retrospective self-report questionnaire designed to assess the presence and severity of traumatic experiences during childhood. It consists of 28 items rated on a 5-point Likert scale, ranging from 1 (never true) to 5 (very often true). It assesses five forms of maltreatment: physical, sexual, and emotional abuse, as well as emotional and physical neglect. It also includes a minimization/denial scale designed to detect the underreporting of traumatic experiences. Each subscale provides a specific score, and an overall total score can also be calculated. The CTQ has been validated in French by Paquette et al. (2004).

Time frame: The CTQ will be completed a single time before the intervention begins.

Medical Outcomes Study Short-Form (MOS-SF 36) (McHorney et al., 1993)

The Medical Outcomes Study Short-Form (MOS-SF-36) (McHorney et al., 1993) is a self-report questionnaire designed to assess quality of life. It consists of 11 questions comprising a total of 36 items. Participants are asked to answer with reference to the previous four weeks across eight subscales: physical functioning, role limitations due to physical health, perceived health, vitality, social functioning and relationships with others, role limitations due to emotional problems, mental health, and health change. The recommended scoring system for the MOS-SF-36 uses a weighted Likert scoring system for each item. Items within each subscale are summed to obtain a summary score for each subscale or dimension. Each of the eight summary scores is then transformed to a scale ranging from 0 (negative health outcomes) to 100 (favorable health outcomes), yielding a score for each subscale. The French version was validated by Leplège (2001).

Time frame: The MOS-SF 36 will be completed on four occasions over the course of the study : Day 1 Week 1, Day 1 Week 2, Day 1 Week 3, follow up 3 months

Toronto Alexithymia Scale (TAS-20) (Bagby et al., 1994)

The Toronto Alexithymia Scale (TAS-20) (Bagby et al., 1994) is a 20-item self-report questionnaire designed to assess the level of alexithymia, that is, difficulty identifying and expressing emotions. Items are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The TAS-20 assesses three dimensions: difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking. A total score above 61 indicates a high level of alexithymia. The scale has been validated in French by Loas et al. (1996).

Time frame: The TAS-20 will be completed on four occasions over the course of the study. Day 1 Week 1, Day 1 Week 2, Day 1 Week 3, follow up 3 months

Difficulties in Emotion Regulation Scale (DERS ; Gratz & Roemer, 2004)

The Difficulties in Emotion Regulation Scale (DERS; Gratz \& Roemer, 2004), in its French version (DERS-F) validated by Dan-Glauser et al. (2015), is a 36-item self-report questionnaire designed to assess difficulties in emotion regulation. Responses are rated on a 5-point Likert scale, ranging from 1 (almost never true) to 5 (almost always true). The scale assesses six dimensions: non-acceptance of emotional responses, difficulties engaging in goal-directed behavior when distressed, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity. Higher scores reflect greater difficulties in emotion regulation.

Time frame: The DERS-F will be completed on four occasions over the course of the study. Day 1 Week 1, Day 1 Week 2, Day 1 Week 3, follow up 3 months

Rosenberg Self-Esteem (Rosenberg, 1965)

The Rosenberg Self-Esteem Scale (Rosenberg, 1965) is a 10-item self-report questionnaire designed to assess global self-esteem. Items are rated on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). It includes five positively worded and five negatively worded items, assessing positive or negative self-perceptions. A higher total score reflects more positive self-esteem. The French version, validated by Vallieres and Vallerand (1990), demonstrates excellent psychometric properties.

Time frame: The Rosenberg Self-Esteem Scale will be completed on four occasions over the course of the study. Day 1 Week 1, Day 1 Week 2, Day 1 Week 3, follow up 3 months