Attachment Style, Trauma, and Reflective Functioning Among Pregnant Women with Substance Use Disorders

Background: Maternal substance use and co-occurring mental health disorders, along with access to treatment, remain significant health equity and social justice challenges for millions of women and children in the U.S. (SAMHSA, 2018). At the micro level, research has found that attachment security is associated with substance use disorders (negatively), emotion regulation (positively), and overall mental health (positively; Thorberg & Lyvers, 2010; Unterrainer, et al., 2017). Adult attachment and the concomitant ability to modulate affect are important for parenting as they have been associated with children’s attachment security and socio-emotional development (Hyysalo, et al., 2021). Furthermore, a parent’s reflective functioning (RF, ability to understand child’s mental states) is thought to be the mechanism by which adult attachment affects parenting practices and a child’s development (Slade, et al., 2005). Although studies have examined relationships among these constructs, none have considered them in pregnant women with SUDs. This study explores the relationships among parental attachment, RF, mental health, and substance use to understand the complex factors that contribute to parenting for mothers with SUDs and identify targets for intervention.

Methods: Baseline data were used from an RCT of a trauma-focused parenting intervention for women with SUDs receiving specialty prenatal care at an urban hospital. For this study, we utilized self-report measures to assess women’s attachment style (Adult Attachment Scale, AAS), mental health (Brief Symptom Inventory, BSI), and trauma symptoms (PTSD Checklist, PCL). The Pregnancy Interview (PI), was used to assess prenatal parental RF. An RF score is determined by reliably coding the PI using a standardized scoring system. Bivariate analyses were computed to examine the relationships among attachment security, RF, mental health, trauma symptoms, and substance use.

Results: Participants were 56 pregnant women (M age= 31; M week of pregnancy =32) who were predominantly white (72%), never married (73%), unemployed (70%); completed high school (40%) and some college (37%); income below $30,000 (73%); reported extensive trauma experiences and symptoms (16.2 episodes; 53% screened in for PTSD); previous child welfare involvement (68%); and histories of heroin/opioid and/or polysubstance use (93%; M=6.8 years; 91% receiving MAT). The majority of participants were in the low prementalizing range for RF (M= 3.31) and endorsed an insecure attachment style (67%). Attachment security (AAS) was negatively associated with trauma symptoms (PCL, r= -.36, p=0.009), overall mental health difficulties (BSI, r= -.48, p=0.000) and marginally with years of polysubstance use (r= -.25, p=0.076). Parental RF was similarly associated with trauma symptoms (r= -.34, p=0.042), mental health difficulties (r= -.33, p=0.047) and years of polysubstance use (r= -.34, p=0.042). No direct association was noted between attachment security and parental RF.

Conclusions: Attachment and RF are similarly associated with mental health, trauma and substance use for these pregnant women with SUDs, but not directly associated with each other. Given the urgent need for effective parenting interventions, social work researchers should further examine the roles played by trauma and mental health with regard to attachment and RF for mothers with SUDs in order to best target salient mechanisms in parenting interventions.