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

Background: Maternal substance use and co-occurring mental health disorders, along with treatment access, 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 SUDs (negatively) and overall mental health (positively; Thorberg & Lyvers, 2010; Unterrainer, et al., 2017). Adult attachment style is important for parenting as its 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 children’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 factors that contribute to parenting for mothers with SUDs and identify intervention targets.

Methods: Baseline data were used from a RCT of a trauma-focused parenting intervention for women with SUDs receiving prenatal care at an urban hospital. 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 RF. An RF score is determined by 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 57 pregnant women (M age = 30.6 years, SD = 4.5; M week of pregnancy = 31, SD = 4.5) who were predominantly white (83%), never married (74%), unemployed (70%); hs graduates (40%) and at least some college (35%); with incomes below $30,000 (74%). They reported extensive trauma histories and symptoms (M episodes = 16.0, SD = 5.0; 51% screened in for PTSD); previous child welfare involvement (64%); and histories of heroin/opioid and/or polysubstance use (93%; M= 7.0 years, SD = 6.5; 91% receiving MAT). Most participants were in the low prementalizing range for RF (M = 3.2, SD = 1.3) and endorsed an insecure attachment style (56%).

Attachment security (AAS) was negatively associated with trauma symptoms (PCL, r= -0.33, p=0.02), overall mental health difficulties (BSI, r= -0.47, p=0.001), and marginally with years of polysubstance use (r= -.25, p=0.09). Prenatal RF was negatively associated with years of polysubstance use (r= -0.39, p=0.003) and marginally with mental health difficulties (BSI, r= -.23, p=0.09) but not with trauma symptoms (PCL, r= -0.12, p=0.4). No direct association was noted between attachment security and parental RF.

Conclusions: Prenatal attachment style and RF are somewhat differentially associated with mental health, trauma, and substance use for these pregnant women with SUDs, perhaps because they draw on different aspects of the self and relationships. Given the need for effective and equitable parenting interventions, social work researchers should tease out the reasons for these differences to best target salient mechanisms in parenting interventions.