Attachment styles adjust responses to stressful events via internal working models. Management of chronic diseases can be taxing enough to trigger attachment behavior. The aim of this study was to investigate the association between attachment styles and medication adherence across time. Attachment style was measured using the Relationship Questionnaire whereas medication adherence was measured using the Morisky Medication Adherence Scale-8. Data were obtained from 80 patients living with hypertension obtained through convenience sampling and the study used a quasi-experimental design. Dialectical Behavior Therapy was given to the experimental group while the control group continued with treatment as usual. The study findings revealed that at baseline medication adherence was lowest among participants with preoccupied (96.7% low, 3.3% moderate), followed by fearful (93.8% low, 6.2% moderate), and dismissing attachment style (91.2% low, 8.8% moderate). A non-significant association was reported (p = .838, Cramer’s V = .101). At endline medication adherence was highest among participants with earned secure attachment (5.3% low, 73.7% moderate, 21.1% high) followed by dismissing (48.3% low, 44.3% moderate, 6.9 high), preoccupied (58.8% low, 35.3% moderate, 5.9% high), and finally fearful attachment style (90.0% low, 10.0% moderate). Association between attachment styles and medication adherence was statistically significant (p < .001, V = .39) with moderate strength. Inferential analysis revealed that the intervention group across time demonstrated higher odds of medication adherence (OR = .11, p <.001) compared to the control, with consistent improvements from baseline to endline. The results indicate that internalized relational models influence patient commitment with treatment regimen and may sabotage satisfaction of psychological needs crucial for motivated health behavior. Incorporation of attachment-informed care into the management of hypertension would boost medication adherence. Adoption of longitudinal study designs in future research would help to investigate how durable earned secure attachment style is over time and its influence on adherence trajectories.

Attachment styles, Medication adherence, Earned secure attachment, Dialectical behavior therapy

Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61(2), 226–244. https://doi.org/10.1037/0022-3514.61.2.226

Bennett, J. K., Fuertes, J. N., Keitel, M., & Phillips, R. (2011). The role of patient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment. Patient Education and Counseling, 85(1), 53–59. https://doi.org/10.1016/j.pec.2010.08.005

Bowlby, J. (1973). Attachment and loss: Separation (Vol. 2). Penguin Group.

Bowlby, J. (1980). Attachment and loss: Vol 3 Loss: Sadness and depression. Basic Books.

Burnier, M., & Egan, B. M. (2019). Adherence in hypertension. Circulation Research, 124(7), 1124–1140. https://doi.org/10.1161/CIRCRESAHA.118.313220

Cavaiola, A. A., Fulmer, B. A., & Stout, D. (2015). The impact of social support and attachment style on quality of life and readiness to change in a sample of individuals receiving medication-assisted treatment for opioid dependence. Substance Abuse, 36(2), 183–191. https://doi.org/10.1080/08897077.2015.1019662

Ciechanowski, P. S., Katon, W. J., Russo, J. E., & Walker, E. A. (2001). The patient-provider relationship: Attachment theory and adherence to treatment in diabetes. American Journal of Psychiatry, 158(1), 29–35.

Costa, V., Oliveira, D., Ferreira, G., & Pedras, S. (2015). Patients’ and spouses’ contribution toward adherence to self-care behaviors in Type 2 Diabetes—ProQuest. Research and Theory for Nursing Practice, 29(4), 276–296. http://dx.doi.org/10.1891/1541-6577.29.4.276

De Pasquale, C., Pistorio, M. L., Vervoux, M., Sapienza, G., Florio, A., Hichy, Z., Ekser, B., Giaquinta, A., & Vervoux, P. (2023). Attachment and parental bond: Impact on psychopathology, mental health and quality of life of hemodialysis patients: A cross-sectional study. BMC Psychology, 11, 210.

Deci, E. L., & Ryan, R. M. (2013). Intrinsic motivation and self-determination in human behavior. Springer Science & Business Media.

Ferreira, P. D., Simoes, J. A., & Velho, D. C. (2024). Adherence to antihypertensive therapy and its determinants: A systematic review. Cureus, 16(5), e59532. https://doi.org/10.7759/cureus.59532

Fraley, R. C., Hudson, N. W., Heffernan, M. E., & Segal, N. (2015). Are adult attachment styles categorical or dimensional? A taxometric analysis of general and relationship-specific attachment orientations. Journal of Personality and Social Psychology, 109(2), 354–368. https://doi.org/10.1037/pspp0000027

Fumaz, C. R., Muñoz-Moreno, J. A., Ferrer, M. J., Ornelas, A., Coll, J., & Clotet, B. (2020). Attachment styles, condomless sex, and drugs in HIV-Positive gay and bisexual men. Journal of Sex & Marital Therapy, 46(1), 35–42. https://doi.org/10.1080/0092623X.2019.1626308

Hamrahian, S. M., Maarouf, O. H., & Fulop, T. (2022). A critical review of medication adherence in hypertension: Barriers and facilitators clinicians should consider. Patient Preference and Adherence, 16, 2749–2757.

Helms, C. B., Turan, J. M., Atkins, G., Kempf, M.-C., Clay, O. J., Raper, J. L., Mugavero, M. J., & Turan, B. (2017). Interpersonal mechanisms contributing to the association between HIV-Related internalized stigma and medication adherence. AIDS and Behavior, 21(1), 238–247. https://doi.org/10.1007/s10461-016-1320-2

Jimenez, X. F. (2017). Attachment in medical care: A review of the interpersonal model of chronic disease management. Chronic Illness, 13(1), 14–27. https://doi.org/10.1177/174239531665316653454

Karveli, S., Galanis, P., Mitropoulou, E. M., Karademas, E., & Markopoulous, C. (2023). The role of attachment styles on quality of life and distress among early‑stage female breast cancer patients: A systematic review. Journal of Clinical Psychology in Medical Settings, 30, 724–739.

Kelly, C. S., Berg, C. A., & Helgeson, V. S. (2020). Adult attachment insecurity and associations with diabetes distress, daily stressful events and self-management in Type 1 Diabetes. Journal of Behavioral Medicine, 43(5), 695–706. https://doi.org/10.1007/s10865-019-00111-7

Kerekes, N., Bador, K., Smedeby, C., Hansen, L., Lundstrom, S., & Eriksson, M. (2024). Attachment styles and sense of coherence as indicators of treatment adherence and completion among individuals with substance use disorder. Research Square. https://doi.org/10.21203.rs.3.rs-4723980/v1

Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. The Guilford Press.

Mate, G. (2004). When the body says no: The hidden cost of stress. Vintage Canada.

McFarland, D. C., Edelstein, A., & Alici, Y. (2024). Trust and the role of attachment: Implications for oncology. In D. C. McFarland, L. Grassi, S. M. Silver, & M. B. Riba (Eds.), The complex role of patient trust in oncology (Vol. 5). Springer, Cham. https://doi.org/10.1007/978-3-031-48-557-2_8

Mutua, D., Singh, P., & Njoroge, G. (2023). Occupational stress among nurses working in the operating theatres at Kenyatta national hospital. International Research Journal of Medicine and Health Sciences, 5(1), 1–20.

Pakdaman, S., Saadat, S. H., Shahyad, S., Ahmadi, K., & Hosseinialhashemi, M. (2016). The role of attachment styles and resilience on loneliness. International Journal of Medical Research & Health Sciences, 5(9S), 268–274.

Pal, B., Dutta, A., Chaudhary, V., Kumari, S., Meenakshi, S., & Murti, K. (2025). Prevalence of antihypertensive medication adherence and associated factors in India: A systematic review and meta-analysis. Hipertensión y Riesgo Vascular, 42(3), 156–164. https://doi.org/10.1016/j.hipert.2024.11.005

Pearson, J. L., Cohn, D. A., Cowan, P. A., & Cowan, C. P. (1994). Earned- and continuous-security in adult attachment: Relation to depressive symptomatology and parenting style. Development and Psychopathology, 6(2), 359–373.

Reyhani, T., Shojafar, A., Gharavi, M. M., Vaghee, S., Kazemeini, T., & Shayan, S. (2016). Effects of emotion regulation training on attachment style of primiparous pregnant women with insecure attachment. Evidence Based Care Journal, 6(1), 19–28.

Rizvi, S. L., Bitran, A. M., Oshin, L. A., Yin, Q., & Ruork, A. K. (2024). The State of the Science: Dialectical Behavior Therapy. Behavior Therapy, 55(6), 1233–1248. https://doi.org/10.1016/j.beth.2024.02.006

Roisman, G. I., Padron, E., Sroufe, L. A., & Egeland, B. (2002). Earned-Secure Attachment status in retrospect and prospect. Childhood Development, 73(4), 1204–1219.

Seifi, H., Tabrizi, M., & Asadzade, H. (2024). Teaching cognitive behavioral techniques on attachment styles, mental health, and optimism in medical students at Islamic Azad University, Mashhad Branch, Iran. Practice in Clinical Psychology, 12(2), 189–200. https://doi.org/10.32598/jpcp.12.2.938.1

Shalev, D., Jacobsen, J. C., Rosenberg, L. B., Brenner, K. O., Seaton, M., Jackson, V. A., & Greer, J. A. (2022). (Don’t) Leave Me Alone: Attachment in Palliative Care. Journal of Palliative Medicine, 25(1), 9–14. https://doi.org/10.1089/jpm.2021.0491

Sharma, M., & Kaushik, P. (2024). The relationship between attachment styles and relationship satisfaction among young adults. The International Journal of Indian Psychology, 12(2). https://doi.org/10.25215/1202.202

Sirois, F. M., Millings, A., & Hirsch, J. K. (2016). Insecure attachment orientation and well-being in emerging adults: The roles of perceived social support and fatigue. Personality and Individual Differences, 101, 318–321. https://doi.org/10.1016/j.paid.2016.06.026

Tan, M. Y. L., McConnell, B., & Barlas, J. (2022). Application of Dialectical Behaviour Therapy in treating common psychiatric disorders: Study protocol for a scoping review. BMJ Open, 12(9), e058565. https://doi.org/10.1136/bmjopen-2021-058565

The Attachment Project. (2024). Earned secure attachment: Transforming your insecure attachment style. https://www.attachmentproject.com/blog/earned-secure-attachment/#:~:text=Earned%20secure%20attachment%20is%20when,outcomes%20of%20a%20secure%20attacher.

Travis, L. A., Bliwise, N. G., Binder, J. L., & Horne-Moyer, H. L. (2001). Changes in clients’ attachment styles over the course of time-limited dynamic psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 38(2), 149–159.

Waari, G., Mutai, J., & Gikunju, J. (2018). Medication adherence and factors associated with poor adherence among type 2 diabetes mellitus patients on follow-up at Kenyatta National Hospital, Kenya. Pan African Medical Journal, 29. https://doi.org/10.11604/pamj.2018.29.82.12639

Wan, J., Wu, Y., Ma, Y., Tao, X., & Wang, A. (2022). Predictors of poor medication adherence of older people with hypertension. Nursing Open, 9(2), 1370–1378. https://doi.org/10.1002/nop2.1183

Wharton, N., & Marcano-Olivier, M. (2023). An exploration of ex-boarding schools' adults’ attachment styles and substance use behaviors. Attachment & Human Development. https://doi.org/10.1080/14616734.2023.2228761

Zalewski, M., Lewis, J. K., & Martin, C. G. (2018). Identifying novel applications of dialectical behavior therapy: Considering emotion regulation and parenting. Current Opinion in Psychology, 21, 122–126. https://doi.org/10.1016/j.copsyc.2018.02.013

Zebardast, A., Rezaei, S., & Rezvandel-Ramzi, F. (2022). The Relationship between Adult Attachment Styles and Adherence to Treatment in Patients with Chronic Disease: The Mediating Role of Resilience. 15(4), 12–24.