Urgent - SO 300 Research Methods Paper On The Attached Articles - 2 Pages

ADDICTION RESEARCH & THEORY, 2016 VOL. 24, NO. 3, 248–260 http://dx.doi.org/10.3109/16066359.2015.1119267

An empirical study of attachment dimensions and mood disorders in inpatient substance abuse clients: The mediating role of spirituality

Naelys Lunaa, Gail Hortona, David Newmanb and Tammy Malloyc

aSocial Work, Florida Atlantic University, Boca Raton, FL, USA; bCollege of Nursing, Florida Atlantic University, Boca Raton, FL, USA; cBehavioral Health of the Palm Beaches, North Palm Beach, FL, USA

ABSTRACT Adult attachment style has been related to both spirituality and psychopathology. This study aimed to test the possible mediating role of two dimensions of spirituality (purpose and meaning in life and perceived relationship with God/higher power) between two attachment dimensions (anxiety and avoidance) and three mood disorders (major depressive disorder, dysthymia and bipolar). In total, 305 clients receiving inpatient substance abuse treatment completed a battery of self-report questionnaires. Path analyses revealed negative associations between the anxiety attachment and all the mood disorders. No significant associations were found for attachment avoidance and the mood disorders. Results also indicated negative associations between the two attachment dimensions and purpose and meaning in life. Concerning the perceived relationship with God/ higher power, attachment avoidance was the only dimension that showed a significant negative association. Mediating effects of meaning in life and the perceived relationship with God/higher power were found between both attachment dimensions and two of the mood disorders: major depressive disorder and dysthymia. Further analyses of the mediating effects revealed that purpose and meaning in life was the factor accounting for the mediating effects. Clinical implications and future direction for research were discussed.

ARTICLE HISTORY

Received 22 June 2015 Revised 5 November 2015 Accepted 9 November 2015 Published online 7 December 2015

KEYWORDS

Attachment dimensions; spirituality; mediating effect; depressive disorders; sub- stance use disorders

Introduction

Research has established high comorbidity rates between substance use disorders (SUDs) and mood disorders (Brienza et al. 2000; Grant et al., 2004; Diaz et al. 2012). Individuals who struggle with these comorbid disorders are more likely to relapse once they experience depres- sive symptoms (Miller et al. 1996; Strowig 2000). In addition, the severity of the drug abuse has been shown to be greater in the presence of co-occurring disorders (Tate et al. 2004). Other researchers have indicated that more frequent injection use, sustained drug use, and higher rates of relapse are found among those individuals who experience SUDs and mood disorders (Marlatt and Gordon 1985; Stein et al. 2003).

Considering the pervasive effects of these co-occurring disorders and the potential influence of mood state on relapse risk (Strowig 2000; Stein et al. 2003), it is crucial that research focus on protective factors that may buffer these effects. This study focuses on two of these factors – attachment and spirituality – that research has suggested may be important in the treatment of individuals struggling with substance abuse issues (Jarusiewics 2000; Flores 2003; Chen 2006; Diaz et al. 2011). This study was designed to test whether two dimensions of

attachment (anxiety and avoidance) are related to three different mood disorders: major depressive disorder, bipolar disorder and dysthymia. In addition, this study examined whether two dimensions of spirituality (exist- ential well-being and religious well-being) mediated expected relationships between attachment and depres- sive symptomatology among a sample of inpatients in treatment for substance use disorders. Before presenting the results of the study, a brief explanation of the attachment and spirituality dimensions are provided along with literature reviews of how the dimensions are related to mood disorder and to each other.

Attachment dimensions

According to Mikulincer and Shaver (2007), attachment style consists of two dimensions – anxiety and avoidance. These two dimensions translate into the four categories of attachment proposed by Bartholomew and Horowitz (1991) that include individuals with secure attachment style (Secure) and those with insecure attachment styles (Preoccupied, Dismissing and Fearful). Similar to Mikulincer and Shaver’s (2007) dimensions, Bartholomew and Horowitz’s model also consists of

CONTACT Dr. Naelys Luna [email protected] Social Work, Florida Atlantic University, 777 Glades Road, Boca Raton, FL 33433, USA � 2015 Taylor & Francis

two dimensions – Self and Others. The Self dimension has to do with the individual’s sense of lovability and worthiness and their consequent expectations concern- ing the availability of others in times of need. The Other model has to do with the individual’s comfort with being in intimate relationships. Thus, Mikulincer and Shaver’s anxious attachment (AX) and avoidant attachment (AV) dimensions correspond with Bartholomew and Horowitz’s dimensions of Self and Others, respectively.

From Mikulincer and Shaver’s (2007) perspective, adults with low AX and low AV (Secure) tend to assume that they are worthy of love and that their partner will be available when needed. They are also relatively willing to have mutually supportive intimate relationships with others. In comparison, those with relatively high AX and low AV (Preoccupied) tend to doubt that their partner will be there when needed because they doubt their lovability and worth. Therefore, they tend to actively demand high levels of support from their intimate relationships, yet expect abandonment. Adults with low AX and high AV (Dismissing) tend to have considerable self-confidence and feel very capable of taking care of themselves. However, they may downplay the import- ance of relationship with others, actively avoiding supporting others and not allowing others to support them. Individuals who manifest high levels of both AX and AV (Fearful) tend to doubt their lovability and worth and their partner’s availability (similar to the Preoccupied style). However, rather than actively demanding support, they tend to be passive. As they tend to distrust others (like the Dismissing style), they may be slow to enter into an emotionally close relation- ship. However, because they are so afraid of being alone, once they are in relationship, they tend to stay even in the face of exploitation and abuse.

Attachment dimensions and mood disorder

Although research has documented the relationships among attachment dimensions and depressive symp- tomatology (Eng et al. 2001; Williams and Riskind 2001; Rholes and Simpson 2004; McMahon et al. 2006), only a few studies have examined these factors in individuals with SUDs (Caspers et al. 2006; Thorberg and Lyvers 2006; De Rick et al. 2009; Diaz et al. 2014). For example, Thorberg and Lyvers (2006) examined a group of 99 individuals attending substance abuse treatment and 59 non-clinical controls concerning their attachment style, degree of fear in intimate situation and their differen- tiation of self. They reported that the participants in treatment indicated significantly higher levels of both insecure attachment and fear of intimacy as well as lower levels of self-differentiation when compared with the

non-clinical participants. Flores (2003) examined the link between attachment style and depressive symptoms among individuals with substance use disorders and argued that inadequate, inconsistent and unreliable parenting during infancy may contribute to impaired emotional regulation among these individuals. These individuals may attempt to cope with the impaired emotional regulation by using substances that numb their psychological distress and/or providing distractive stimulation. He argued that substance use disorders are ‘both a consequence of and a solution to the absence of satisfying relationships’ (Flores 2003, p. 50) in these individuals’ lives.

Similarly, De Rick et al. (2009) explored the relation- ships between alexithymia, psychiatric disorders and attachment dimensions among 101 individuals attending inpatient treatment for alcoholism. Findings revealed that �86% of the entire sample reported insecure attachment dimensions and difficulty regulating affect and developing and maintaining interpersonal relation- ship. Results also showed that three different subgroups of clients can be distinguished according to their attachment dimensions. The first group, which included a little over half of the clients, exhibited an impaired attachment system. These individuals had serious diffi- culty regulating their emotions and establishing secure interpersonal relationships. Another subgroup involving over a third of the participants reported moderate attachment impairment, whereby they showed difficulty in either regulating their emotions or in establishing relationships. The last subgroup, including about 14% of the sample, involved individuals with secure attachment systems who were able to regulate their affects and establish good interpersonal relationships.

Finally, a recent study examined attachment style, spirituality and depressive symptomatology among 77 clients attending a residential treatment facility (Diaz et al. 2014). These authors reported that individuals with insecure attachment style and lower levels of existential purpose and meaning in life were more likely to have higher levels of depression compared with individuals with secure attachment style and high levels of purpose and meaning.

Spirituality dimensions

The conceptualization of spirituality as being distinct from religion has been a topic of debate among scholars (Mohr 2006; Koenig 2008). Koenig (2008) presented the evolution of the way spirituality has been defined over several decades. Originally it was associated with faith practices or religious individuals; however, as spirituality has been examined in health and mental health research,

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it has been expanded beyond religion to include values, positive character traits and positive mental health states (i.e. meaning in life, connections with others, peaceful- ness, well-being, harmony and hope) (Koenig 2008). Dalmida (2006) perceived spirituality as being a wider construct than religion in that it involves a personal relationship with a higher power. Similarly, Hood et al. (2009, p. 289) held that ‘religious experiences constitute a more restricted range than the diversity that character- ises spiritual experiences’. Seidlitz et al. (2002) argued that religion and spirituality are indeed similar in that both involve a search for the sacred (a divine being or of a sense of ultimate reality or truth). However, these authors differentiated between the two by pointing out that spirituality is concerned with an individual’s personal search whereas religion is a group effort to direct and to provide approval of that search.

Along the same lines, religion has been defined as an organised system of beliefs manifested in rituals, values and guidelines of conduct (Mohr 2006). These differen- tiations seem to be consistent with Canda and Furman (2010, p. 76) who have argued that religion is ‘an institutionalized. . .pattern of values, beliefs, symbols, behaviors and experiences’ associated with a particular community that may include spirituality as one of its defining features. Spirituality, on the other hand, both includes and transcends religion. They define spirituality as being ‘a universal quality of human beings and their cultures related to the quest for meaning, purpose, morality, transcendence, well-being and profound rela- tionships with ourselves, others and ultimate reality’ (Canda and Furman 2010, p. 5).

Thus, it appears that spirituality is a multidimensional construct that involves the search for individual meaning and/or purpose in life and connectedness to oneself, others and the transcendent (Diarmuid 1994; Seidlitz et al. 2002; Canda and Furman 2010; Oman 2014). Cook (2004) reviewed 265 books and articles regarding spirituality and provided a comprehensive conceptual- ization of the term. Cook stated that spirituality is ‘a distinctive, potentially creative and universal dimension of human experience’ (Cook 2004, p. 548) that may be formed through the relationship with self, with others or with that which is beyond the self. Spirituality is also defined as an essential factor that provides purpose and meaning to life (Cook 2004). The spirituality dimensions of purpose and meaning and relationships with others and the transcendent are also discussed in the work of Canda and Furman (2010). It is the concepts of existential well-being (purpose and meaning in life) and religious well-being (relationship with God) that will be examined in this study.

Spirituality and mood disorder

The literature on spirituality and depression has docu- mented the protective value of spirituality for different populations (Nelson et al. 2002; Doolittle and Farrell 2004; Hill et al. 2005; Sorajjakool et al. 2008). Interestingly, research studies in this area seem to focus on two components of spirituality: (1) spiritual existential purpose and meaning in life and (2) religious beliefs. For instance, in a qualitative study exploring the role of spirituality and meaning in life among 15 clients diagnosed with severe depression, Sorajjakool et al. (2008) reported three themes of interest. First, the authors indicated that depressed clients reported a lack of spiritual connection evidenced by a disconnection with God, the community in general and oneself. Clients also reported that spirituality played an important role in their struggles with depression, whereby they experi- enced a deep yearning for a sense of meaning in their lives trying to make sense of their pain and struggles with depression.

Another study conducted by Hill et al. (2005) examined spirituality and distress in palliative care and concluded that those clients who expressed anger at God or had negative religious coping skills were more depressed. Similarly, Doolittle and Farrell (2004) reported that, among urban clients, those who scored higher on spiritual assessment have fewer depressive symptoms. More specifically, those clients who had a belief in a higher power, engaged in prayers and reported having a relationship with a higher power experienced lower levels of depression. Examining both spirituality and religion and their relationship to depression among 162 terminally ill patients with cancer and AIDS, another study reported a negative correlation between meaning in life and peacefulness and depression (Nelson et al. 2002); however, no relationship was found between religious well-being and depression among these individuals.

Although the associations between spirituality and depression have been examined in various clinical populations yielding interesting results about the dis- tinction of protective quality of different dimensions of spirituality, recent research concerning spirituality as a protective factor for individuals with depressive symp- tomatology and SUDs is scant. In a substance abuse sample, two important factors of spirituality, purpose and meaning and the relationship with God, were examined among 111 clients attending residential treat- ment (Diaz et al. 2011). Findings indicated that the existential dimension of spirituality (purpose and mean- ing in life) showed a strong and inverse relationship with depressive symptoms, whereas the relatedness to God

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aspect showed a significant positive relationship with depressive symptoms (Diaz et al. 2011). Other research has also shown that spirituality is a key factor regarding positive treatment outcomes and recovery for substance use disorders (Jarusiewics 2000; Chen 2006). Spirituality has been correlated to abstinence during or after treatment (Jarusiewics 2000) and has been noted as ‘a powerful antagonist of addiction’ (Unterrainer et al. 2012, p. 68).

Attachment, religion and spirituality

A considerable body of literature has arisen concerning relationships between the religious aspect of spirituality and attachment styles and dimensions (Kirkpatrick and Shaver 1992; Kirkpatrick 1998; Grandqvist and Hagekull 2000; Byrd and Boe 2001; Eurelings-Bontekoe et al. 2005; Hood et al. 2009). For example, researchers have found that secure attachment was positively related to higher levels of religiosity, more positive images of God and perceptions of greater closeness to God than those reported by individuals with insecure styles (Kirkpatrick and Shaver 1992; Kirkpatrick 1998; Grandqvist and Hagekull 2000; Byrd and Boe 2001; Eurelings-Bontekoe et al. 2005).

Hood et al. (2009) have pointed out that the qualities attributed to God (at least the God of Christian traditions) tend to correspond closely to the attributes associated with secure attachment figures in early childhood. Similarly, Grandqvist et al. (2012) have indicated (citing Kaufman 1981) that ‘The idea of God is the idea of an absolutely adequate attachment figure’ (Grandqvist et al. 2012, p. 804) and have argued that, for individuals who believe in a personal God, God can provide a sense of ‘felt security’ and a ‘safe haven’ similar to that provided by early attachment figures. They tested the two pathways in a series of four experimental design studies utilising a sample of adults in Israel and found that individual differences in levels of attachment anxiety and avoidance were related to individual differences in attachment to and images of God. Those with more secure adult attachment tended to have more secure attachment to God, whereas those with more insecure adult attachment tended to have more insecure attach- ment to God that corresponded with their levels of anxiety and avoidance in their close personal relation- ships. In addition, they reported that God provided a safe haven and secure base to their respondents that was significantly reduced by the presence of insecure attachment.

Although there are numerous studies of attachment and religion as discussed above, only two studies in the current literature have examined attachment and

spirituality (as opposed to religion/religiosity). In one study, Horton et al. (2012) explored differences in spirituality dimensions, religious background and God images associated with adult attachment style using a sample of individuals in residential treatment for sub- stance use issues. They found that religious background, God image and the religious well-being dimension of the spirituality measures did not vary by attachment style. However, the existential purpose and meaning dimen- sion of spirituality did vary such that those with a secure attachment style had significantly higher levels of purpose and meaning in life than any of the insecure attachment styles. In a later study, Diaz et al. (2014) reported that whereas both attachment style and the purpose/meaning dimension of spirituality were related to depressive symptomatology, purpose/meaning was the best predictor of depression level among individ- uals attending a residential substance abuse treatment facility.

Study rationale and hypotheses

As the literature review above shows, attachment and spirituality dimensions are related to depressive symp- toms. However, attachment dimensions also seem to be related to spirituality among individuals with SUDs whereby individuals with attachment avoidance/anxiety appear to have less purpose and meaning in life than individuals with secure attachment style (Horton et al. 2012). Is it possible, then, that the relationship between attachment and depressive symptoms is mediated by spirituality? Researchers are in agreement that, in response to adaptive evolutionary forces that promote survival, children start to form attachment bonds starting at birth (Bowlby 1982; Mikulincer and Shaver 2007). By the age of six or seven months an attachment style and an internal working model of self have begun to develop and are solidly in place by the age of 2 years (Mikulincer and Shaver 2007). The style is then very likely to be carried forward through childhood and adolescence into adulthood (Bartholomew and Horowitz 1991; Mikulincer and Shaver 2007).

Spirituality, on the other hand, is thought to begin to develop at some point after infancy because children in the sensorimotor stage are unable to differentiate self from other or to experience an awareness of an abstract such as God (Cartwright 2001). Hood et al. (2009) argued that, based on Piaget’s understanding of cognitive development, children are not capable of understanding the complexities of adult religious thought until adoles- cence. However, they also noted that there is consider- able evidence for a genetic component to spirituality, indicating a probability that humans are born with a

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neurobiological system predisposed to religious/spiritual thought. Indeed, Richert and Granqvist (2014, p. 170) have argued that ‘the relationship with God develops in temporal conjunction with the maturation of the attachment system and the cognitive developments associated with that maturation’.

It should be noted, however, that (as might be expected given the methodological issues associated with questioning very young and preverbal children) none of the studies reviewed by Hood et al. (2009) or Oman (2014) concerning religious/spiritual develop- ment during childhood were conducted using a sample of children under the age of 4 years. Therefore, very little is known about the possible development of spirituality in infancy and toddlerhood. However, as a great deal is known about the development of attach- ment during those developmental stages, we are assuming that for the purposes of this study that attachment precedes the development of spirituality. Our purpose for this study was, therefore, to explore the possibility that attachment may influence individ- uals’ levels of existential purpose and meaning in life and/or relatedness to God, which in turn influences mood disorder. Specifically, this study aimed to explore: (1) to what extent attachment dimensions directly predicted different types of mood disorders including major depressive disorder (MDD), bipolar disorder (BIP) and dysthymia (DYS) among individuals attend- ing substance abuse treatment and (2) whether the relationships between attachment dimensions and mood disorders were mediated by spirituality. Based on the above reviewed literature, we hypothesised that there would be a positive relationship between attach- ment anxiety and all three mood disorders; we also predicted a positive relationship between attachment avoidance and the three mood disorders. The positive effect of attachment dimensions on the mood disorders was expected to be mediated by levels of purpose and meaning in life. We anticipated that religious well-being would not show a significant mediation effect between the attachment dimensions and the three mood disorders.

The findings from this research may increase our understanding regarding the relative importance of both attachment dimensions and spirituality and their impact on depressive symptoms among individuals with SUDs. These factors may contribute distinctively to the development and severity of depression in this popu- lation. Mental health professionals may then have a way of identifying a focus of clinical attention for clients with comorbid SUDs and mood disorders addressing both their spirituality and their interpersonal relationships.

Methods

Participants

Clients were recruited from a residential substance abuse treatment center located in southeastern Florida after receiving approval from the Institutional Review Board. The treatment facility is a for-profit agency that uses the 12-steps model of Alcohol Anonymous (AA) to provide a wide range of mental health services including detoxification, inpatient, residential, partial hospitaliza- tion and intensive outpatient. Attendance at this agency is voluntary. Clients consented to participate in our study after having completed the detoxification phase at the facility and being deemed medically and psychiatric- ally stable to move into a lower level of care. As part of the facility’s regular procedure, staff met with each client within 72 h of his or her discharge from detox. At that time, staff conducted a psychosocial assessment evalu- ation and asked the client to fill out a battery of assessment tools to determine diagnosis and treatment. Staff then informed the clients about the study, obtained informed consent and asked the client to complete an additional self-report survey measuring spiritual well- being provided by the study researchers. Clients who refused participation were excluded from the study. In total, 305 clients were recruited over a period of 1 year and agreed to participate in the study. The mean age of participants was 33.7 years. Approximately 62% of participants were male, and almost all were White non-Hispanic (89%).

Measures

The Experiences in Close Relationships Scale-revised

The Experiences in Close Relationships Scale-revised (ECR-R) (Fraley et al. 2000) is a 36-item self-report scale used to assess adult romantic attachment style. The ECR-R comprises two subscales (18 items each) measuring AX (e.g. ‘I worry a lot about my relation- ships’) and AV (e.g. ‘I find it difficult to allow myself to depend on romantic partners’). Respondents are asked how they feel in emotionally intimate relationships. Each item is rated on a 7-point Likert scale ranging from ‘completely agree’ to ‘completely disagree’. The scales are almost uncorrelated (r¼0.11) with coefficient alphas above 0.90 (Riggs et al. 2007). Other researchers have documented high internal consistency, test–retest reliability as well as construct, predictive and discrim- inant validity (Crowell et al. 1999). For this sample, Cronbach alphas were 0.89 for the attachment anxiety and 0.90 for attachment avoidance.

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The Spiritual Well Being Scale

The Spiritual Well Being Scale SWB (Ellison 1983) was used to measure spirituality. This is a 20-item self-report instrument that contains two subscales: (1) the Existential Well Being subscale (EWB or ‘meaning’) (e.g. ‘I don’t know who I am, where I came from, or where I am going’) and (2) the Religious Well Being subscale (RWB or ‘God/higher power’) (e.g. ‘I have a personally meaningful relationship with God’). The SWB has a 6-point Likert-type scale ranging from 1¼strongly disagree, 2¼mostly agree, 3¼disagree, 4¼agree, 5¼moderately agree, and 6¼strongly agree. It has demonstrated good psychometric properties. Coefficient alphas of 0.97 and a test–retest coefficient of 0.93 have been reported for the RWB, whereas the EWB obtained 0.90 and 0.80, respectively (Saunders et al. 2007). Cronbach alphas for this sample were 0.92, 0.93 and 0.89 for the SWB, RWB and EWB, respectively.

The Millon Multixial Clinical Inventory-III

The Millon Multixial Clinical Inventory-III (MCMI-III) (Millon et al. 2009) is the latest revision of this widely used 175-item self-report questionnaire that consists of 28 scales: four scales measure the validity and response style (validity index, disclosure, desirability and debase- ment), 14 scales measure personality disorders and 10 scales measure clinical syndromes including dysthymia, alcohol dependence and drug dependence. For the purpose of this study, the MCMI was utilised to measure mood disorder traits (dysthymia, major depressive disorder and bipolar). This instrument has demonstrated good psychometric properties (Millon 1997; Craig and Olson 1998; Craig and Olson 2001), and has been used as an assessment tool in several studies of individuals who abuse drugs (Craig and Olson 1998; Calsyn et al. 2000; Teplin et al. 2004; Diaz et al. 2009).

The MCMI-III scores the psychological traits and symptoms as follows: (1) a score �85 is indicative of all the traits and symptoms for a given mental disorder at a clinical level; (2) scores between 75 and 85 indicate the presence of traits and symptoms associated with the disorder, below clinical levels and (3) a score 575 is considered to lack clinical significance. For the purpose of this study, three scales assessing the clinical syndromes of mood (dysthymia, major depressive disorder and bipolar) were utilized.

Data analyses

Correlation analyses were conducted to examine the relationship between the independent (anxiety [AX] and

avoidance [AV] attachment dimensions), mediating (existential purpose and meaning in life [EWB] and religious well-being [RWB]) and dependent variables (major depressive disorder [MDD], dysthymia [DYS] and bipolar disorder [BIP]). Three separate path analysis models using the AMOS software (Chicago, IL) were used to examine the relationships between the two independent variables, avoidant attachment styles (AV), anxious attachment styles (AX), relationship with higher power (RWB) and meaning and purpose in life (EWB) on the three mood disorders in the study: MDD, DYS and BIP. The primary endogenous variables in this study were the three mood disorders. Both the RWB and EWB were second level endogenous variables that mediated the effects of attachment styles on the mood disorders of MDD, DYS and BIP. The overall fit of these models were assessed using chi-square, comparative fit index (CFI) and overall R2. All of these indexes assess the discrepancies between the data and the hypothesised model. Both the CFI and R2 values range from 0 to 1 with higher score indicating better fit, whereas lower score indicated less discrepancy for the chi-square.

Results

Correlation analyses

Table 1 presents the results of the correlation analyses examining the relationships between the main variables of the study. MDD showed significant and positive correlations with DYS and BIP symptoms, both attach- ment dimensions, and the RWB dimension of spiritu- ality. In addition, there was a significant negative correlation between MDD and the EWB dimension of spirituality.

DYS showed a significant and positive correlation with BIP and both attachment dimensions. However, in contrast to MDD, DYS was significantly and negatively correlated with both EWB and RWB. Unlike either MDD or DYS, BIP showed a significant positive correlation only with the AX attachment dimension.

Table 1. Correlations of mood disorders attachment dimensions and spirituality subscales.

Variable Mean (SD) 1 2 3 4 5 6

1. MDD 64.63 (28.11) – 2. DYS 68.45 (26.23) 0.79

b –

3. BIP 59.37 (20.83) 0.24b 0.308b – 4. AX 67.04 (16.49) 0.33b 0.412b 0.207b – 5. AV 53.20 (21.03) 0.29b 0.264b 0.03 0.349b – 6. RWB 38.30 (11.07) 0.18b �0.142a 0.10 �0.07 �0.155a – 7. EWB 39.97 (10.98) �0.489b �0.565b �0.03 �0.462b �0.472b 0.396b

ap�0.05. bp�0.01.

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Finally, AX showed a significant positive correlation with AV and a significant negative correlation with EWB whereby AV showed a significant negative correlation with both EWB and RWB.

Path model analyses

There were three distinct path analyses conducted to investigate the relationships among attachment style dimensions, the three mood disorders (MDD, DYS and BIP) and the mediating effects of spirituality as measured by RWB and EWB. Results indicated that the overall fit of the models is generally adequate. The chi-square for all three models is40.05; the CFI for DYS and MDD are low but adequate with a CFI¼0.89 and 0.87, respect- ively, and with a poor fit for BIP with a CFI¼0.82. The overall R2 ranges from a high of 0.33 for DYS to a low of 0.07 for BIP. MDD fell in the middle with an R2¼0.23.

Figures 1, 2 and 3 show the results of the path model analyses for MDD, DYS and BIP, respectively. In each figure, the rectangles are observer variables where AV and AX are exogenous variables and RWB and EWB, acting as mediators, are both exogenous and endogenous variables. The mood disorder (MDD, DYS or BIP) is the outcome endogenous variable. To best reflect the rela- tionship between the spirituality subscales, the error terms for RWB and EWB were correlated. Individual results for direct and mediating effects shown in the three path model analyses are discussed below.

Major depressive disorder

Figure 1 and Table 2 show the results of the path analysis for MDD. Results indicated that there was a significant positive direct effect of AX on MDD (�¼0.14, p¼0.02), but not a significant effect of AV on MDD

Figure 2. Attachment styles mediated by spirituality predicting dysthymia.

Figure 1. Attachment styles mediated by spirituality predicting MDD.

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(�¼0.05, p¼0.35). AX had a significant negative direct effect on EWB (�¼�0.36, p50.01) but was not significant on RWB (�¼�0.04, p¼0.52). AV had significant negative direct effects on both EWB (�¼�0.37, p50.01) and RWB (�¼�0.15, p¼0.01). RWB did not show a significant direct effect in predicting MDD (�¼�0.01, p¼0.89) whereas EWB had a significant direct effect (�¼�0.39, p50.01). Regarding indirect effects, results indicated that there were significant effects for both AX and AV as mediated

by RWB and EWB in predicting MDD (�¼0.14, p¼0.02 and �¼0.14, p¼0.02, respectively).

Dysthymia

Figure 2 and Table 2 show the results of the path analysis for DYS. Similar to MDD, there was a significant positive direct effect of AX on DYS (�¼0.21, p5 0.01), but no significant effect of AV on DYS (�¼�0.03, p¼0.53). AX had a significant negative direct effect on EWB but

Table 2. Standardised path weights for direct, indirect and total effect of the mood disorders.

Standardised effects

Direct Indirect Total

Dx Endogenous Exogenous Estimate S.E. p Value Estimate p Value Estimate p Value

MDD RWB 5– Anxiety �0.04 0.04 0.517 EWB 5– Avoidance �0.37 0.03 50.001 EWB 5– Anxiety �0.36 0.03 50.001 RWB 5– Avoidance �0.15 0.03 0.012 MDD 5– RWB �0.01 0.14 0.888 MDD 5– EWB �0.39 0.17 50.001 MDD 5– Avoidance 0.05 0.08 0.345 0.14 0.016 0.2 50.001 MDD 5– Anxiety 0.14 0.1 0.016 0.14 0.016 0.28 50.001

Dysthymia RWB 5– Anxiety �0.03 0.04 0.582 EWB 5– Avoidance �0.37 0.03 50.001 EWB 5– Anxiety �0.35 0.03 50.001 RWB 5– Avoidance �0.16 0.03 0.009 Dysthymia 5– RWB 0.07 0.12 0.179 Dysthymia 5– EWB �0.5 0.15 50.001 Dysthymia 5– Avoidance �0.03 0.07 0.526 0.17 0.001 0.14 0.016 Dysthymia 5– Anxiety 0.21 0.08 50.001 0.17 0.001 0.38 50.001

Bipolar RWB 5– Anxiety �0.04 0.04 0.488 EWB 5– Avoidance �0.36 0.03 50.001 EWB 5– Anxiety �0.36 0.03 50.001 RWB 5– Avoidance �0.15 0.03 0.011 Bipolar 5– RWB 0.1 0.12 0.105 Bipolar 5– EWB 0.02 0.14 0.751 Bipolar 5– Avoidance �0.03 0.06 0.627 �0.02 0.75 �0.05 0.432 Bipolar 5– Anxiety 0.24 0.08 50.001 �0.01 0.853 0.23 50.001

Figure 3. Attachment styles mediated by spirituality predicting bipolar.

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was not significant on RWB (�¼�0.35, p50.01; �¼�0.03, p¼0.58, respectively). AV had significant negative direct effects on both EWB and RWB (�¼�0.37, p50.01; �¼�0.16, p¼0.01, respectively). RWB did not show a significant direct effect on DYS (�¼�0.07, p¼0.18) whereas EWB had a significant direct effect (�¼�0.50, p50.01). Results indicated that there were significant indirect effects for both AX and AV as mediated by RWB and EWB on DYS (�¼0.17, p50.01 and �¼0.17, p50.01, respectively).

Bipolar disorder

Figure 3 and Table 2 show results of the path analysis for BIP. Similar to MDD and DYS, there was a significant positive direct effect of AX on BIP (�¼0.24, p5 0.01), but no significant effect of AV on BIP (�¼�0.03, p¼0.63). AX had a significant negative direct effect in predicting EWB (�¼�0.36, p50.01) but was not significant in predicting RWB (�¼�0.04, p¼0.49). AV had significant negative direct effects in predicting both EWB and RWB (�¼�0.36, p50.01; �¼�0.15, p¼0.01, respectively). Unlike MDD and DYS, there were no significant indirect effects for either AX or AV as mediated by RWB and EWB in predicting BIP (�¼�0.01, p¼0.75 and �¼�0.02, p¼0.85, respectively).

Discussion

Recent research has shown that insecure adult attach- ment styles are related to difficulty in regulating negative mood among individuals with substance use issues (Thorberg and Lyvers 2010). Other research has sug- gested that the meaning and purpose dimension of spirituality is positively related to depressive symptoms in this same population (Diaz et al. 2011). However, this study is the first to examine both of these factors simultaneously in association with mood disorder. The aim of this study was to examine the relationships between attachment dimensions (anxiety and avoidance) and three mood disorders (MDD, bipolar and dys- thymia) among a clinical sample of individuals attending substance abuse treatment, with special attention focused on the possible mediating role of spirituality (existential purpose and meaning, and religious well-being or perceived relationship with God). The results will be discussed separately for the direct effects of the attach- ment dimensions on the mood disorders, and the direct effects of the attachment dimensions on spirituality. Then results for the mediating effects of the two spirituality dimensions will be discussed.

Direct effects

Attachment dimensions and mood disorder

As hypothesised, attachment anxiety showed a direct positive effect with all of the mood disorders. Those individuals with a strong sense of lovability/worthiness (low levels of the attachment anxiety) were more likely to report low levels of the symptomatology for MDD, dysthymia and bipolar. This finding is consistent with previous research (Kassel et al. 2007) proposing that people with anxious romantic attachment use substances to decrease their negative feelings related to being abandoned by others. Interestingly, attachment avoid- ance was not significantly related to any of the mood disorders. That is, individuals’ willingness to be intimate with others and to develop trusting relationships did not seem to be related to levels of depressive symptom- atology in this sample.

Attachment dimensions and spiritual dimensions

In regard to the direct effect of the attachment dimen- sions on the spirituality dimensions, we found that both attachment anxiety and avoidance showed significant negative direct effects on the purpose and meaning dimension of spirituality for all the three mood dis- orders. For all three moods disorders, the higher the level of attachment anxiety, the lower the level of purpose and meaning in life. That is, the more an individual was afraid of being abandoned by their romantic relation- ship, the less purpose and meaning he or she was experiencing. The higher the level of attachment avoid- ance, the lower the level of existential purpose and meaning. It seems that the less interested an individual was in sharing him or herself intimately with another, the less purpose and meaning he or she was experien- cing. There were no significant direct effects of attach- ment anxiety on the religious dimension of spirituality. An individual’s fear of being abandoned in his or her current romantic relationship did not affect his or her feelings of closeness with God. However, individuals with higher levels of attachment avoidance tended to have lower levels of religious well-being. That is, the less likely an individual was in sharing him or herself intimately with another, the less he or she was interested in being close to God.

Mediating effects

When we examined the possible mediating role of the spiritual dimensions on the relationships between attachment dimensions and the three mood disorders, we found that religious well-being did not significantly

256 N. LUNA ET AL.

mediate the relationship between either of the attach- ment dimensions and any of the mood disorders. It seems that the perceived relationship with God did not affect the levels of mood disorder symptoms in this sample. However, we did find that existential purpose and meaning in life mediated the effect of both of the attachment dimensions on MDD and dysthymia symp- tomatology. Therefore, it appears that the presence of existential purpose and meaning in life may be an important factor in reducing the negative effects of attachment issues manifested in important relationships for individuals with comorbid MDD, dysthymia and SUDs. However, our results would suggest that purpose and meaning may not be as important a factor for those with bipolar disorder.

The differential effects of purpose and meaning on bipolar and the other two mood disorders could perhaps be explained by research that has documented bipolar as being a separate condition from the affective disorders in that it is 85% heritable (Barnett and Smoller 2009). The genetic disposition for mania has been described as independent of the liability for depression (McGuffin et al. 2003), whereas other subtypes of depressions are proposed to be based on the internal meanings arising from feelings of loss (i.e. the attachment system). Thus, these authors speculate whether the strong neurobio- logical components associated with bipolar may be more salient than the influence of existential purpose and meaning in the life of individuals affected by a dual diagnosis of bipolar and a substance use disorder.

Clinical implications and conclusions

Our findings have multiple implications that may be useful in informing clinical interventions pertaining to individuals with co-occurring substance use and mood disorders. First, our results suggest that increasing the existential purpose and meaning dimension of spiritu- ality may help individuals with adult attachment issues reduce their levels of depressive symptoms associated with dysthymia or MDD. Findings also seem to indicate that increasing individuals’ connectedness to a higher power may not be as effective. Perhaps future research will find that the reason that purpose and meaning work to relieve depressive symptoms in this population stems from the emotional benefits of having close interpersonal relationships that provide purpose and meaning in an individual’s life. It is possible that having someone to care about and care for may give an individual purpose and meaning in life that may ultimately buffer the development and effect of depressive symptoms. Alternatively, perhaps purpose and meaning acts as a substitute for close relationships. We speculate whether

an individual can have a satisfying life and positive sense of self if they have sufficient purpose and meaning regardless of whether they have meaningful close relationships. In either case, finding interventions that help to increase purpose and meaning in life among dually diagnosed individuals would appear to be of clinical benefit.

Second, our findings indicated that, although bipolar disorder is a mood disorder, it is quite different from MDD and dysthymia. Whereas individuals with MDD and dysthymia stemming from early attachment issues may benefit from interventions that increase existential purpose and meaning, individuals with bipolar may not respond as well. Perhaps the difference lies in the genetics of the disorder that drive its manifestation. Both MDD and dysthymia are disorders of depression while bipolar may be considered as a disorder of both depression and mania. It may be that during a manic episode individuals experience a sense of purpose and meaning which is not present during a depressive episode, whereas those with MDD or dysthymia do not experience those high levels of purpose and meaning at all.

Limitations and future direction for research

Several limitations need to be considered when inter- preting the results of this study. First, we used a cross- sectional design so we can only describe the relationship among the factors and not make a direct causal statement; however, path analysis has been used in other studies to explore relationships among variables to build statistical models (Shipley 2002; Ye et al. 2014). This does not allow for an exploration of how attach- ment style dimensions and spirituality evolve over time as a result of being in substance use treatment, while simultaneously exploring changes in depressive symp- toms. Future studies need to employ a longitudinal design that could provide evidence related to the extent to which substance use treatment influence the relation- ships between these variables. Second, most of the participant in the study self-identified as Caucasian, and thus, findings cannot be generalizable to other ethnic/ racial groups. In addition, other sociodemographic factors including having financial resources (i.e. medical insurance) and receiving services at a private, for-profit agency that is based on the 12 steps model whose population represents clients attending a residential treatment facility need to be taken into consideration when interpreting and generalising the results. Other important information about the participants including drug of choice, frequency of use, SUDs diagnoses and severity were not collected in this study. Future studies

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should capture this information as these elements may have a potential effect on the variables under examin- ation in this investigation. In addition, this study examined the relationships among attachment style dimensions and spirituality and three mood disorders. Future studies may consider exploring the relationships between these factors and other mental health disorders. In addition, future research could focus on other possible aspects of spirituality not examined in this study. For example, recent research has explored relationships between purpose and meaning in life and forgiveness (Lyons et al. 2010, 2011). It would be interesting to explore possible relationships between attachment dimensions and these factors.

Another limitation involves the operationalization of spirituality. Koenig (2008) indicated that instruments measuring spirituality assess it in terms of religious practices, positive mental health or both. Many research studies, in their analyses, do not distinguish between spirituality and religious well-being. In fact, investiga- tions exploring the impact of spirituality on different clinical outcomes measure this construct using tools design to capture elements related to religious coping skills and practices (Doolittle and Farrell 2004; Hill et al. 2005; Sorajjakool et al. 2008). Koenig (2008) suggests that studies using the SWB, such as our study, should analyse the existential and religious well-being separately to avoid presenting misleading results. Although analyses in this study followed Koenig’s (2008) suggestions, several researchers are questioning whether it is appro- priate to attribute positive mental health states (i.e. purpose and meaning in life) as part of spiritual dimensions (Krause 2008; Tsuang et al. 2007).

In addition, it is important to consider that the presence of a mood disorder and/or substance use disorder could influence how clients answered questions about their attachment style and relationship with other people. Recent research has identified an association between depression and romantic relationships that is more complex than the one tested in this study (Finkbeiner et al. 2013; Baker and McNulty 2015; Rehman et al. 2015; Woods et al. 2015). For example, Finkbeiner et al. (2013) studied a mediation model in which they found a causal path between relationship distress (high levels of negative interaction and low levels of positive interactions) and depression as well as a reciprocal path between depression (couple interaction processes) and relationship distress. That is, they found that relationship distress resulted in depression and that depression resulted in relationship distress. On the other hand, Baker and McNulty (2015) found that confronta- tional behaviours (which tend to be distressing in close relationships) were actually associated with fewer

relationship problems over time among couples experi- encing severe relationship problems unless one or both of the partners was depressed. In these cases, depression was found to be related to decreased motivation to resolve their interpersonal problems. Neither of these studies explored how attachment might be related to relationship distress. However, longitudinal research by Rehman et al. (2015) found that higher levels of depressive symptoms at T1 were related to a larger decline in relationship satisfaction over time. When anxiety symptoms were controlled, depressive symptoms no longer predicted relationship satisfaction. They suggested that attachment anxiety may be responsible for producing stress in close relationships that then adds to depression. It would be interesting in future research to test a more complex model in which pathways between attachment dimensions, spirituality dimensions and depressive symptoms are examined for reciprocity.

It would be useful to understand what kinds of interventions can be implemented to increase existential purpose and meaning in life among individuals in treatment for substance use issues. It would also be interesting to explore how individuals with early attach- ment issues and subsequent adult relationship problems experience existential purpose and meaning in their lives and how meaningful interpersonal relationships can provide purpose and meaning or how purpose and meaning can overcome relationship difficulties. Future investigations may also consider replicating our study and expanding it using other mental health disorders and examining gender and race/ethnicity differences.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

References

Baker LR, McNulty JK. 2015. Adding insult to injury: partner depression moderates the association between partner- regulation attempts and partners’ motivation to resolve interpersonal problems. Pers Soc Psychol Bull. 4(6):839–852.

Barnett JH, Smoller JW. 2009. The genetics of bipolar disorder. Neuroscience 164:331–343.

Bartholomew K, Horowitz LM. 1991. Attachment styles in young adults: a test of a four-category model. J Pers Soc Psychol. 61:226–244.

Bowlby J. 1982. Attachment and loss: vol. 1: attachment. New York (NY): Basic Books.

Brienza RS, Stein MD, Chen MH, Gogenini A, Sobota M, Maksad J, Hu P, Clarke J. 2000. Depression among needle exchange program and methadone maintenance clients. J Subst Abuse Treat. 18:331–337.

258 N. LUNA ET AL.

Byrd KR, Boe A. 2001. The correspondence between attach- ment dimensions and prayer in college students. Int J Psychol Relig. 11:9–14.

Calsyn DA, Wells EA, Fleming C, Saxon AJ. 2000. Changes in Millon Clinical Multiaxial Inventory scores among opiate addicts as a function of retention in methadone maintenance treatment and recent drug use. American Journal of Drug and Alcohol Abuse 26(2):297–309.

Canda ER, Furman LD. 2010. Spiritual diversity in social work practice. New York (NY): Oxford University Press.

Cartwright KB. 2001. Cognitive developmental theory and spiritual development. J Adult Dev. 8(4):213–220.

Caspers KM, Yucuis R, Troutman B, Spinks R. 2006. Attachment as an organizer of behavior: implications for substance abuse problems and willingness to seek treatment. Subst Abuse Treat Prev Policy 1(32). doi: 10.1186/1747- 597X-1-32.

Chen G. 2006. Social support, spiritual program, and addiction recovery. Int J Offender Ther Comp Criminol. 50:306–323.

Cook CC. 2004. Addiction and spirituality. Addiction 99(5):539–551.

Craig RJ, Olson RE. 1998. Stability of the MCMI-III in a substance-abusing inpatient sample. Psychol Rep. 83(3):1273–1274.

Craig RJ, Olson RE. 2001. Adjective descriptions of personality disorders: a convergent validity study of the MCMI-III. J Pers Assess. 77(2):259–271.

Crowell JA, Fraley RC, Shaver PR. 1999. Measurement of individual differences in adolescent and adult attachment. In: Cassidy J, Shaver PR, editors. Handbook of attachment: theory, research, and clinical applications. New York (NY): Guilford Press. p. 434–465.

Dalmida SG. 2006. Spirituality, mental health, physical health and health related quality of life among women with HIV/ AIDS: integrating spirituality into mental health care. Issues Ment Health Nurs. 27:185–198.

De Rick A, Vanheule S, Verhaeghe P. 2009. Alcohol addiction and the attachment system: an empirical study of attach- ment style, alexithymia and psychiatric disorders in alcoholic patients. Subst Use Misuse 44:99–114.

Diarmuid OM. 1994. Spirituality, recovery, and transcendental meditation. Alcohol Treat Q. 11:169–183.

Diaz N, Horton EG, Malloy T. 2014. Depressive symptoms, attachment style, and spirituality among individuals attend- ing substance abuse treatment. J Soc Ser Res. 4(3):313–324.

Diaz N, Horton G, McIlveen J, Weiner M, Nelson J. 2009. Dysthymia among substance abusers: an exploratory study of individual and mental health factors. Int J Ment Health Addict. 7(2):357–367.

Diaz N, Horton EG, McIlveen J, Weiner M, Williams LB. 2011. Spirituality, religiosity and depressive symptoms among inpatient substance abusers. J Relig Spirituality Soc Work Soc Thought 30(1):71–87.

Diaz N, Horton E G, Weiner M. 2012. Dysthymia, major depression, and double depression among individuals receiving substance abuse treatment. Health 4(12): 1229–1237.

Doolittle BR, Farrell M. 2004. The association beween spirituality and depression in an urban clinic. J Clin Psychiatry 6(3):114–118.

Eurelings-Bontekoe EHM, Hekman-Van Steeg J, Verschuur MJ. 2005. The association between personality, attachment,

psychological distress, church denomination and the god concept among a non-clinical sample. Ment Health Relig Culture 8(2):141–154.

Ellison CW. 1983. Spiritual well-being: conceptualization and measurement. J Psychol Theol. 11:330–340.

Eng W, Heimberg RG, Hart TA, Schneier FR, Liebowitz MR. 2001. Attachment in individuals with social anxiety disorder: the relationship among adult attachment styles, social anxiety, and depression. Emotion 1:365–380.

Finkbeiner NM, Epstein NB, Falconier MK. 2013. Low intimacy as a mediator between depression and clinic couple relationship satisfaction. Pers Relationship. 20:406–421.

Flores PJ. 2003. Addiction as an attachment disorder. New York (NY): Jason Aaronson.

Fraley C, Waller NG, Brennen KA. 2000. An item response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol. 78(2):350–365.

Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Dufour MC, Compton W, Pickering RP, Kaplan K. 2004. Prevalence and co-occurrence of substance abuse disorders and independent mood disorders and anxiety disorders: results for the National Epidemiologic Survey on Alcohol and related Conditions (NESARC). Arch Gen Psychiatr. 61:807–816.

Grandqvist P, Hagekull B. 2000. Religiosity, adult attachment, and why ‘‘singles’’ are more religious. Int J Psychol Relig. 10(2):111–123.

Granqvist P, Mikulincer M, Gewirtz V, Shaver PR. 2012. Experimental findings on God as an attachment figure: normative processes and moderating effects of Internal Working Models. J Pers Soc Psychol. 103(5):804–818.

Hill J, Paice JA, Cameron JR, Shott S. 2005. Spirituality and distress in palliative care consultation. J Palliative Med 8(4):782–788.

Hood RW, Hill PC, Spilka B. 2009. The psychology of religion: an empirical approach. 4th ed. New York (NY): Guilford Press.

Horton EG, Diaz N, Weiner M, Malloy T. 2012. Adult attachment style, spirituality, and religiosity among individ- uals in treatment for substance use disorders. FL Public Health Rev. 9:121–131.

Jarusiewics B. 2000. Spirituality and addiction: relationship to recovery. Alcohol Treat Q. 18:99–110.

Kassel JD, Wardle M, Roberts JE. 2007. Adult attachment security and college student substance use. Addict Behav. 32:1164–1176.

Kaufman GD. 1981. The theological imagination: constructing the concept of god. Philadelphia (PA): Westminster.

Kirkpatrick LA. 1998. God as a substitute attachment figure: a longitudinal study of adult attachment style and reli- gious change in college students. Pers Soc Psychol Bull. 24:961–973.

Kirkpatrick LA, Shaver PR. 1992. Attachment theory and religion: childhood attachments, religious beliefs and con- version. J Sci Study Relig. 29:315–334.

Koenig HG. 2008. Concerns about measuring ‘‘spirituality’’ in research. J Nerv Ment Dis. 196(5):349–355.

Krause N. 2008. The kingdom of heaven is in the midst of you: reflections on social relationships in the church and health in late life. Philadelphia (PA): Templeton Foundation Press.

ADDICTION RESEARCH & THEORY 259

Lyons G, Deane F, Caputi P, Kelly P. 2011. Spirituality and the treatment of substance use disorders: an exploration of forgiveness, resentment and purpose in life. Addict Res Theory 19(5):459–469.

Lyons G, Deane F, Kelly P. 2010. Forgiveness and purpose in life as spiritual mechanisms of recovery from substance use disorders. Addict Res Theory 18(5):528–543.

Marlatt GA, Gordon JR. 1985. Relapse prevention. New York (NY): Guilford Press.

McGuffin P, Rijsdijk F, Andrew M, Sham P, Katz R, Cardno A. 2003. The heritability of bipolar affective disorder and the genetic relationship to unipolar depression. Arch Gen Psychiatr. 60:497–502.

McMahon CA, Barnett B, Kowalenko NM, Tennant CC. 2006. Maternal attachment of mind moderates the impact of postnatal depression on infant attachment. J Child Psychol Psychiatry 47:660–669.

Mikulincer M, Shaver PR. 2007. Attachment in adulthood: structure, dynamics, and change. New York (NY): Guilford Press.

Miller WR, Westerberg VS, Harris RJ, Tonigan JS. 1996. What predicts relapse? Prospective testing of relapse models. Addiction 91:S155–S171.

Millon T. 1997. Millon clinical multiaxial inventory-III manual. 2nd ed. Minneapolis (MN): National Computer System.

Millon T, Millon C, Davis R, Grossman S. 2009. MCMI-III manual. 4th ed. Minneapolis (MN): Pearson Education, Inc.

Mohr WK. 2006. Spiritual issues in psychiatric care. Perspect Psychiatr Care 42(3):174–183.

Nelson CJ, Rosenfeld B, Breitbart W, Galietta M. 2002. Spirituality, religion, and depression in the terminally ill. Psychosomatics 43(3):213–220.

Oman D. 2014. Defining religion and spirituality. In: Paloutzian RF, Park CL, editors. Handbook of the psych- ology of religion and spirituality. New York (NY): Guilford Publications. p. 23–47.

Rehman US, Evraire LE, Karimiha G, Goodnight JA. 2015. Actor-partner effects and the differential roles of depression and anxiety in intimate relationhsips: a cross-sectional and longitudinal analysis. J Clin Psychol. 71(7):715–724.

Rholes WS, Simpson JA. 2004. Ambivalent attachment and depressive symptoms: the role of romantic and parent-child relationships. J Cogn Psychother. 18:67–78.

Richert RA, Granqvist P. 2014. Religious and spiritual development through childhood. In Paloutzian RF, Park CL, editors. Handbook of the psychology of reli- gion and spirituality. New York (NY): Guilford Publications. p. 165–182.

Riggs SA, Sahl G, Greenwald E, Atkinson H, Paulson A, Ross CA. (2007). Family environment and adult attachment as

predictors of psychopathology and personality dysfunction among inpatient abuse survivors. Viol Vict. 22(5):575–598.

Saunders SM, Lucas V, Kuras L. 2007. Measuring the discrepancy between current and ideal spiritual and religious functioning in problem drinkers. Psychol Addict Behav. 21:404–408.

Seidlitz L, Abernathy AD, Duberstein PR, Evinger JS, Chang TH, Lewis B. 2002. Development of the Spiritual Transcendence Index. J Sci Study Relig. 41:439–453.

Shipley B. 2002. Start and stop rules for exploratory path analysis. Struct Equat Model. 9(4):554–561.

Sorajjakool S, Aja V, Chilson B, Ramirez-Johnson J, Earll A. 2008. Disconnection, depression, and spirituality: a study of the role of spirituality and meaning in the lives of individuals with severe depression. Pastoral Psychol. 56:521–532.

Stein MD, Solomon DA, Herman DS, Anderson BJ, Miller I. 2003. Depression severity and HIV injection risk behaviors. Am J Psychiat. 160:1659–1662.

Strowig AB. 2000. Relapse determinants reported by men treated for alcohol addiction: the prominence of depressed mood. J Subst Abuse Treat. 19:469–474.

Tate SR, Brown SA, Unrod M, Ramo DE. 2004.Context of relapse for substance-dependent adults with and with- out comorbid psychiatric disorders. Addict Behav. 29: 1707–1724.

Teplin D, O’Connell T, Daiter J, Varenbut M. 2004. A psychometric study of the prevalence of DSM-IV personality disorders among office-based methadone maintenance patients. Am J Drug Alcohol Abuse 30(3):515–524.

Thorberg FA, Lyvers M. 2006. Negative mood regulation (NMR) expectancies, mood, and affect intensity among client in substance disorder treatment facilities. Addict Behav 31(5):811–820.

Tsuang MT, Simpson JC, Koenen KC, Kremen WS, Lyons MJ. 2007. Spiritual well-being and health. J Nerv Ment Dis 195:673–680.

Unterrainer H-F, Huber H-P, Selzer K, Fink A. 2012. ‘‘Spiritus contra spiritum?’’ Spiritual well-being and depression among male alcohol dependents in treatment. Alcohol Treat Q. 30:67–77.

Williams NL, Riskind JH. 2004. Adult romantic attachment and cognitive vulnerabilities to anxiety and depression: examining the interpersonal basis of vulnerability models. J Cogn Psychother. 18:7–24.

Woods SB, Priest JB, Denton WH. 2015. Predicting improve- ment in depression across therapies using indicators of romantic relationship functioning: a preliminary investiga- tion. Am J Fam Ther. 43:44–56.

Ye X, Yao Z, Liu W, Fan Y, Xu Y, Chen S. 2014. Path analysis to identify factors influencing health skills and behaviors in adolescents: a cross-sectional survey. PLoS One. 9(8):e104406.

260 N. LUNA ET AL.

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