Comparing the Early Maladaptive Schemas, Attachment and Coping Styles in Opium and Stimulant Drugs Dependent Men in Kerman, Iran.

BACKGROUND: Today, the society's need to find the roots of a few thousand-year old substance abuse and the drugs addiction crisis has increased to the extent that it has become a problem within our country. The problem of substance dependence is not only about drug abuse, but it is actually the interrelationship of the person and the dependency on drugs. This study aimed to compare early maladaptive schemas, attachment styles, and coping styles in men dependent on opiates and stimulants in Kerman, Iran.
METHODS: This was a comparative descriptive study. The study population consisted of men dependent on opiates and stimulants who referred to addiction treatment clinics in Kerman. Therefore, 150 patients (75 opium addicted men and 75 men dependent on drugs) were selected. The participants completed the Young schema questionnaire-short form (YSQ-SF), adult attachment scale (AAS), and Young coping styles questionnaire (YCSQ). The research data were analyzed using independent t-test and SPSS software.
FINDINGS: Mean age of patients using opium was 27.9 ± 3.35 years and mean age of patients using stimulant drugs was 25.6 ± 3.41 years (18-60 years old). The results showed that there was no difference between the early maladaptive schemas and coping styles in men dependent on opium and stimulants. However, there was a significant difference between attachment styles in men dependent on opium and stimulants. The mean score of avoidant and ambivalent styles in men dependent on stimulants was higher.
CONCLUSION: Knowledge on the distinctions of early maladaptive schemas, attachment styles, and coping styles in substance abuse patients helps the therapists to conduct more effective treatment strategies tailored to the type of substance used in order to provide behavior modification.

Introduction

Opium and stimulant drugs dependency is a psychiatric disorder with biological, psychological, and social dimensions and is one of the major problems in Iran. Mental and personality characteristics of an addict is not solely dependent on drug abuse, but before substance dependency, these people have numerous psychiatric and personality disorders which are intensified after dependency.1 Drug abuse, due to its devastating effects on the brain, severe obsessive-compulsive disorder (OCD), and association with significant psychiatric symptoms, has imposed serious challenges on treatment and prevention programs.2 The abuse of stimulants results in a progressive condition that, if left untreated, will lead inevitably to severe dependency, serious psychological damage, and can even cause premature death.3 Stimulants cause severe psychological dependency. For example, crack or cocaine dependency creates the fastest and strongest dependency.4

Several factors contribute to the etiology of substance abuse. By interaction with each other, these factors lead to the onset of drug dependency.5 The processes of drug dependency are influenced by the beliefs and attitudes of drug dependent individuals, and their attitudes correspond to their cognitive and emotional responses. Attitudes have an important role in life, thoughts, and behaviors of individuals and communities. Individuals have special perspectives towards objects and various issues. These perspectives are derived from their knowledge of them, their feelings towards them, and their tendency to do something about them. Meanwhile, cognitive schemes have a special place due to their importance in the interpretation of particular situations.6 In the cognitive approach, schema is a common cognitive framework that the individual has towards a specific topic. An individual’s schemes have an important role in thinking, feeling, behaving, and way of communicating with others, and if they are not formed correctly, they can be considered a factor in substance abuse. Early maladaptive schemas are constant and long-term issues caused during childhood and transferred to adulthood and are mainly inefficient.7

The investigation showed that there is a significant positive relationship between anxiety, insecure attachment styles, the number of substances consumed, and their severity. There is also a relationship between attachment style, the role of mediator of early maladaptive schemas, dysfunctional attitudes, confidence, and drug abuse.4 The findings of this study suggested that there was a difference between early maladaptive schemas and attributional style in the two groups of addicted and non-addicted men.6 Addicts suffered from high levels of early maladaptive schemas and had a more pessimistic attributional style.5 A study that was conducted on 260 students showed that the schemes of social isolation/alienation, dependency/incompetence, caught/obedience, self-control/inadequate self-discipline were the most important predictors of addictive tendencies.8

Individuals show coping responses towards schemas which include cognitive and behavioral efforts to overcome or minimize the effects of stress, as well as certain behaviors or strategies that are manifested through three behavioral styles, which include excessive compensation behavior, surrender, and avoidance.9 Coping responses include all responses that exist in the behavioral treasury of the individual towards threats. In other words, it includes all unique and special ways that the patient reveals excessive compensation, surrender, and avoidance through them.10 When a person habitually uses a specific coping response, the coping responses are tied to the coping styles. Therefore, the coping style is a trait and the coping response is a mode or state which may be involved in drug dependency.11

Research results showed that there was a significant relationship between interaction-oriented coping style and low consumption of tobacco and marijuana, and disengagement coping style was a strong predictor for smoking marijuana.12 In a study on university students it was found that those who used problem-oriented coping style consume less alcohol.13 The findings of a study on 184 patients taking ecstasy showed that the coping style of these patients was mostly emotion oriented, and symptoms of depression, anxiety, and trauma can be seen in them.14 Another study showed that the coping styles of common people were mostly problem-oriented and the coping styles of people consuming methamphetamine were mostly emotion-oriented.15 The findings of this study showed that there was a significant relationship between addicted and non-addicted adolescents regarding personality characteristics and coping styles.15 The scores of addicted adolescents were significantly higher in neuroticism and emotion-focused coping style and were lower than healthy adolescents (independent) regarding agreeableness, conscientiousness, and problem-focused coping style.11

One of the other factors influencing drug addiction is the attachment style. According to Bowlby theory, people are born with a biological mental system called the attachment behavioral system. This system has adaptive value, and it leads individuals towards maintaining closeness to or intimacy with important people in life or the image of attachment to the people whom the child feels safe with in threatening situations, to increase the chances for survival and reconciliation.16 Studies have shown that there is a significant positive relationship between avoidant attachment style and alcohol17 and narcotics use.18 Moreover, high consumption of tobacco and cannabis and low consumption of alcohol had a significant relationship with insecure attachment styles. There was a significant relationship between cannabis (marijuana) use and ambivalent and avoidant attachment styles.19 Mortazavi et al. found that those using drugs, compared with healthy individuals, have insecure attachment styles and less emotional maturity.20 The results revealed that there was a significant relationship between attachment styles among patients with substance abuse disorders and attachment styles of non-addicted individuals. Between the secure and insecure attachment styles, and the severity of substance abuse disorders there was a negative and positive significant relationship, respectively.21 In this study, the researchers sought to compare early maladaptive schemas, attachment styles, and coping styles in men dependent on opiates and stimulants in Kerman, Iran.

Methods

This was a comparative descriptive study. The statistical population consisted of opioid dependent men and men dependent on stimulant drugs who referred to drug rehabilitation clinics in Kerman. Each group consisted of 75 addicted volunteers who had referred to the rehabilitation clinics for the treatment of addiction in the summer of 2012. The 2 groups were similar in terms of demographic characteristics, such as age and education level. After coordination with the addiction rehabilitation clinics, in order to encourage the participants to cooperate in the study, the aims and importance of the study were explained to them. They were also informed that they were able to request the results of their questionnaires from the researcher. After obtaining the consent of the patients, the questionnaires were distributed and completed individually.

The data collection tools consisted of the young schema questionnaire-short form (YSQ-SF), adult attachment scale (AAS), and young coping styles questionnaire (YCSQ). The YSQ-SF was designed by Young.22 The YSQ-SF contains 75 items and 15 subscales including emotional deprivation, triggered, mistrust/abuse, social isolation/alienation, defectiveness/shame, entitlements, dependence/incompetence, busy/obedience, sacrifice, emotional inhibition, uncompromising standards, restraint/poor self-discipline, vulnerable against loss, failure, and disease. According to previous studies, the reliability and validity of this questionnaire was 0.89 based on Cronbach's alpha for the whole test and above 0.85 for the whole scales.23 The AAS was made by Hazan and Shaver.24 AAS includes 15 items and 3 subscales consisting of secure attachment, avoidant, and ambivalent styles. Khavaninzadeh et al. have reported the reliability of the questionnaire as 0.84.25

The YCSQ was made by Young. It includes the young avoidance inventory (YAI) which consists of 40 items scored on a 6-point scale.26 High scores indicated a general pattern of avoidance schemes. The young compensation inventory questionnaire (YCIQ) included 47 items scored on a 6-point scale. High scores indicate a general pattern of excessive compensation.26 The reliability of this questionnaire was estimated as 0.79 using the split method and 0.7 based on Cronbach's alpha.27 The data were analyzed using t-test to test the hypothesis and SPSS software (version 18, SPSS Inc., Chicago, IL, USA).

Results

Mean age of individuals using narcotics was 27.9 ± 3.35 years and patients using stimulant drugs was 25.6 ± 3.41 years (age range: 18-60 years). Among the opium addicted patients, 21 were below diploma, 32 had diploma, and 22 were higher than diploma. In the group using stimulant drugs, 19 patients were below diploma, 36 had diploma, and 20 were higher than diploma. Table 1 illustrates the mean and standard deviation of the sample group regarding the studied variables.

Table 1

T-test statistics of the studied variables

Indicators	Stimulant drugs	Narcotics	t	P
	Mean ± SD	Mean ± SD
Emotional deprivation	16.27 ± 6.02	14.85 ± 5.77	1.460	0.144
Abandonment	17.00 ± 7.17	15.80 ± 7.25	1.019	0.310
Mistrust/abuse	15.29 ± 5.98	14.20 ± 6.27	1.092	0.276
Social isolation/alienation	14.73 ± 5.82	13.13 ± 6.53	1.580	0.115
Defectiveness/shame	12.83 ± 4.70	12.87 ± 6.38	0.044	0.965
Failure	14.20 ± 5.45	13.76 ± 6.37	0.455	0.650
Dependence/incompetence	14.03 ± 5.76	14.11 ± 6.33	0.081	0.930
Vulnerability to losses and unemployment	13.27 ± 5.73	13.36 ± 6.15	0.096	0.920
Busy	13.91 ± 5.42	13.89 ± 5.67	0.015	0.980
Submission	13.92 ± 4.70	14.27 ± 6.23	0.380	0.701
Sacrifice	15.95 ± 6.62	17.13 ± 6.54	1.105	0.271
Emotional inhibition	14.65 ± 5.78	14.64 ± 5.91	0.014	0.980
Uncompromising standards	15.32 ± 6.01	16.75 ± 6.17	1.430	0.154
Deserved	15.73 ± 6.25	15.64 ± 5.39	0.098	0.922
Self-discipline/self-sufficient	15.47 ± 5.72	14.92 ± 6.02	0.570	0.610
Avoidance style	16.05 ± 4.08	14.39 ± 4.27	2.440	0.016
Secure style	16.92 ± 4.09	16.32 ± 4.01	0.907	0.420
Ambivalent style	16.53 ± 4.081	14.35 ± 3.84	3.370	0.001
Young’s excessive compensation	139.39 ± 38.13	142.81 ± 43.13	0.516	0.607
Young-Rai avoiding	125.63 ± 32.57	121.72 ± 33.73	0.722	0.472
Young’s Schema	222.56 ± 57.30	219.32 ± 66.48	0.320	0.750
Attachment styles	49.50 ± 9.59	45.05 ± 8.72	2.970	0.003
Coping styles	265.10 ± 63.60	264.53 ± 71.31	0.044	0.965

SD: Standard deviation

Results of table 1 show no difference in the mean scores of early maladaptive schemas and its subscales between the coping styles of men dependent on opiates and men dependent on stimulant drugs (P > 0.050). Nevertheless, there was a significant difference between the avoidant and ambivalent attachment styles among men dependent on opiates and men dependent on stimulant drugs (P < 0.050).

Discussion

The findings of this study showed that there was no significant difference between the overall mean score of opioid dependent men and men dependent on stimulant drugs regarding early maladaptive schema subscales and coping styles subscales. In the opioid dependent group, among the subscales of early maladaptive schemas, the excessive compensation component had an above normal mean. Furthermore, among the subscales of coping styles, components of triggered and emotional deprivation had an above normal mean. In addition, in the stimulant drug dependent group, among the subscales of early maladaptive schemas, excessive compensation component had an above normal mean, and among the subscales of coping styles, components of dedication and uncompromising standards had an above normal mean. The findings of this study suggested that there was a difference between early maladaptive schemas in both addicted and non-addicted men,6 and the addicts suffer from high levels of early maladaptive schemas.5 The study findings also showed that the schemes of social isolation/alienation, dependence/incompetence, busy/obedience, and restraint/poor self-discipline were the most important predictors of tendency towards addiction.8

The findings of the study revealed that the most common coping style among stimulant drug addicts was emotion oriented style.14 The most common coping style among healthy individuals and stimulant drug addicts was problem oriented and emotion oriented coping style, respectively.15 Based on the literature review, the majority of conducted researches had compared early maladaptive schemas and coping styles among two groups of addicted and non-addicted individuals and no differences was observed among these two groups. However, in the present study, both groups consisted of addicts. The researcher did not find any previous literature regarding the comparison of early maladaptive schemas and coping styles among two groups of addicts.

The findings of this study showed that the mean scores of the opioid-dependent men and men dependent on stimulant drugs had significant differences regarding ambivalent and avoidant attachment styles. This finding was consistent with the results of studies which showed that addicted individuals had insecure attachment and ambivalent styles.17-20 Nevertheless, no study was found that compared the styles of attachment between two addicted groups.

Conclusion

The identification of personality factors that affect drug addiction can improve the diagnosis and treatment of drug dependency. Providing timely consulting services and psychological consultation can prevent drug dependency to some extent. Therefore, the application of schema therapy can be effective in combination with other therapeutic modalities. Considering the differences in attachment styles in substance dependent patients, ambivalent individuals have a strong tendency to establish close relationships, but they also have concerns of rejection. These individuals have a negative image of themselves, but a positive attitude towards others. The fundamental problem of avoidance style is self-reliance. When they are likely to be rejected by others, they try to maintain a positive image of themselves by denying the attachment needs. These individuals have high self-esteem and observe the establishing of close relationships with others as less important. More effective treatment strategies can be employed for patients based on their attachment style.