Marshall, E. M., Karantzas, G. C., Chesterman, S., & Kambouropoulos, N. (2024). Unpacking the association between attachment insecurity and PTSD symptoms: The mediating role of coping strategies. Psychological Trauma: Theory, Research, Practice, and Policy, 16(1), 86–91. https://doi.org/10.1037/tra0001270
Key Points
- Attachment insecurity, specifically attachment anxiety and avoidance, is associated with greater PTSD symptoms following a trauma. This occurs through the mechanism of maladaptive coping strategies used by insecurely attached individuals, namely hyperactivating strategies for those high in attachment anxiety and deactivating strategies for those high in attachment avoidance.
- The severity of the traumatic event moderates the association between maladaptive coping strategies and PTSD symptoms, such that these coping strategies are more strongly associated with PTSD symptoms when trauma severity is high.
- The findings provide proof of concept for the trauma and attachment model proposed by Marshall and Frazier (2019), demonstrating the mediating role of coping strategies in the link between attachment orientations and PTSD symptoms.
- The research highlights the need for therapeutic approaches that focus on minimizing reliance on maladaptive coping strategies in a manner tailored to client attachment orientations. Fostering felt security and assisting with building more adaptive coping skills is critical.
Rationale
Prior research has established robust links between attachment insecurity and PTSD symptoms following trauma (Woodhouse et al., 2015).
However, research has yet to systematically test the long-held assumption that this link occurs through reliance on maladaptive coping strategies used by insecurely attached individuals to achieve their attachment goals in the absence of responsive support.
This study provides proof of concept for a recently proposed trauma and attachment model (Marshall & Frazier, 2019). This model argues that those high in attachment anxiety engage in hyperactivating strategies designed to intensify distress and draw attention/comfort from others.
Those high in attachment avoidance engage in deactivating strategies designed to suppress distressing emotions and maintain independence. While intended to achieve proximity or distance, these secondary strategies foster PTSD symptoms.
The model also proposes that trauma severity moderates this process, such that secondary strategies are even more problematic when trauma severity is high, as approach coping is critical for processing trauma emotions to prevent PTSD. When trauma severity is lower, secondary strategies are less problematic as approach coping is less critical.
Method
- Design: Cross-sectional online survey
- Participants: 302 trauma-exposed adults from the U.S. and Australia (74.5% female, mean age 35 years)
- Materials:
- Attachment orientations: Adult Attachment Questionnaire (AAQ; Simpson et al., 1996).
- Coping strategies: Ways of Coping-SF questionnaire (WOC-SF; Karantzas, 2012)
- PTSD symptoms: Trauma Symptoms Inventory-2
- Trauma severity: Participant ratings of distress, threat of death, and injury for each trauma experienced
- Analysis:
- Mediation analysis using conditional process analysis
- Moderated mediation with trauma severity moderating the coping strategies → PTSD symptoms paths
Sample
The 302 participants were adults (>18 years) from the U.S. (91.4%) and Australia (8%) who had experienced a traumatic event at some point across their lifespan.
The sample was mostly female (74.5%) with a mean age of 35 years. Most were married/in a committed relationship (62.2%). Participants reported a diverse range of trauma experiences.
Statistical Measures
- Mediation analysis tested indirect effects of attachment variables on PTSD symptoms through coping strategies
- Moderated mediation analysis tested whether trauma severity moderated the association between coping strategies and PTSD symptoms
- 5000 bootstrapped samples were used to construct bias-corrected confidence intervals around indirect effects
- Cronbach’s alpha assessed scale reliability of multi-item measures
Results
As hypothesized, attachment anxiety and avoidance both indirectly predicted greater PTSD symptoms through their positive associations with maladaptive coping strategies.
Specifically, attachment anxiety predicted greater use of both hyperactivating strategies (b = .28, p < .001) and deactivating strategies (b = .16, p = .005). Hyperactivating (b = 13.57, p < .001) and deactivating (b = 7.27, p < .001) strategies in turn predicted more PTSD symptoms.
Similarly, attachment avoidance predicted greater use of deactivating strategies (b = .27, p < .001), which predicted more PTSD symptoms.
These indirect effects were moderated by trauma severity. The associations of both hyperactivating and deactivating strategies with PTSD symptoms were stronger at high levels of trauma severity.
Insight
A key insight from this study is that attachment anxiety may lead individuals to rely not only on hyperactivating strategies designed to maximize proximity, but also deactivating strategies to modulate distress when hyperactivation becomes too overwhelming.
This highlights the complex interplay between primary and secondary regulation strategies employed by anxiously attached people to achieve felt security.
The findings also provide the first empirical support for the proposition that secondary attachment strategies are more problematic for PTSD symptoms when trauma severity is high.
This corroborates attachment theory’s premise that the greater the distress, the more critical primary coping and social support is for adaptive functioning post-trauma.
Together, the results lend credence to calls for attachment-informed psychotherapy that helps minimize reliance on maladaptive secondary strategies in a manner tailored to clients’ attachment tendencies. Fostering felt security is paramount.
Strengths
- Rigorous statistical analysis (mediation, moderated mediation)
- Included diverse trauma experiences across the lifespan
- Findings support and extend prior theory on attachment processes
- Highlights clinical implications regarding tailored psychotherapy
Limitations
- Cross-sectional design limits causality assumptions
- Retrospective self-report could yield recall biases
- Sample not demographically diverse (mostly white, female, American)
Implications
The findings underscore the value of attachment-based case conceptualization to identify PTSD risk and inform treatment planning.
Clinicians should assess attachment orientations to identify those at risk for more severe PTSD symptoms after trauma, especially individuals with insecure attachments
For clients high in attachment anxiety, the results suggest assisting emotion regulation skills and distress tolerance alongside validating coping attempts to meet unmet attachment needs.
For clients high in attachment avoidance, maintaining autonomy while gently processing avoided trauma emotions may prevent excessive deactivating strategies.
The moderating effect of trauma severity also highlights the need for early intervention post-trauma when distress is most acute. Later intervention risks entrenchment of maladaptive secondary strategies.
Overall, an attachment-informed approach can enhance trauma processing to prevent PTSD development.
References
Primary reference
Marshall, E. M., Karantzas, G. C., Chesterman, S., & Kambouropoulos, N. (2024). Unpacking the association between attachment insecurity and PTSD symptoms: The mediating role of coping strategies. Psychological Trauma: Theory, Research, Practice, and Policy, 16(1), 86–91. https://doi.org/10.1037/tra0001270
Other references
Briere, J. (2011). Trauma Symptom Inventory-2 (TSI-2): Professional manual. PAR.
Karantzas, G. C., McCabe, M. P., & Cole, S. (2012). Chronic illness and relationships. In P. Noller & G. C. Karantzas (Eds.), The Wiley-Blackwell handbook of couples and family relationships (pp. 406–419). Wiley. https://doi.org/10.1002/9781444354119.ch28
Marshall, E. M., & Frazier, P. A. (2019). Understanding posttrauma reactions within an attachment theory framework. Current Opinion in Psychology, 25, 167-171. https://doi.org/10.1016/j.copsyc.2018.08.001
Simpson, J. A., Rholes, W. S., & Phillips, D. (1996). Conflict in close relationships: An attachment perspective. Journal of Personality and Social Psychology, 71(5), 899–914. https://doi.org/10.1037/0022-3514.71.5
.899
Woodhouse, S., Ayers, S., & Field, A. P. (2015). The relationship between adult attachment style and post-traumatic stress symptoms: A meta-analysis. Journal of Anxiety Disorders, 35, 103–117. https://doi.org/10.1016/j.janxdis.2015.07.002
Keep Learning
Here are some suggested discussion questions for a college class based on this research:
- How might early childhood attachment experiences influence the development of attachment orientations and associated coping tendencies observed in adulthood? What are the developmental processes at play?
- To what extent are secondary attachment strategies consciously chosen vs automatic processes outside conscious awareness? What might this mean for attempts to change coping tendencies in therapy?
- Could the entrenchment of maladaptive secondary coping strategies explain why PTSD becomes chronic for some trauma survivors? What perpetuates PTSD over time from an attachment perspective?
- How feasible is it for therapists to provide the secure base apparently needed to help clients minimize problematic secondary coping strategies? What are the challenges and ethical issues involved?
- To what extent is the proposal to match therapeutic techniques to individual differences in attachment valid? Might a ‘one size fits all’ approach also be effective if grounded in attachment theory principles? What might be the relative costs and benefits of each approach?
