Measuring Attachment Security in Patients With Advanced Cancer

Psycho-Oncology
Psycho-Oncology 18: 490499 (2009)

Published online 26 September 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1417
Measuring attachment security in patients with advanced

cancer: psychometric properties of a modified and brief
Experiences in Close Relationships scale
Christopher Lo1,2, Andrew Walsh2, Mario Mikulincer3, Lucia Gagliese1,2,4, Camilla Zimmermann1 and Gary
Rodin1,2
1
Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, and Psychosocial Oncology and Palliative Care Research
Division, Ontario Cancer Institute, University Health Network, Toronto, Canada
2
Behavioural Sciences and Health Research Division, Toronto General Research Institute, University Health Network, Toronto, Canada
3
New School of Psychology, Interdisciplinary Center Herzliya, Herzliya, Israel
4
Department of Kinesiology and Health Science, York University, Toronto, Canada
Abstract
* Correspondence to: 9-232
Eaton North, Toronto
General Hospital, 200
Elizabeth St., Toronto, Ont.,
Canada M5G 2C4. E-mail:
chrislo@uhnresearch.ca
Received: 5 March 2008

Revised: 30 May 2008
Accepted: 3 June 2008
Objective: Attachment security has been identied as an important buer of distress in patients
with cancer and other medical illnesses but current measures have not been adapted for this
population who may be older, in long-term stable relationships, and suering from considerable
disease burden. This study reports on (1) the psychometric properties of a modied 36-item
Experiences in Close Relationships scale (ECR), adapted for this population; and (2) the
validity of a brief 16-item version of our modied scale.
Methods: A modied ECR (ECR-M36) was constructed by rephrasing relevant items to
refer more generally to people with whom one feels close, instead of specically in relation to
ones romantic partner(s). Patients with metastatic gastrointestinal (GI) and lung cancer
completed the ECR-M36 and other scales tapping self-esteem, social support, and depressive
symptoms on two occasions within a period of 46 months. Based on factor analyses of the
ECR-M36, 16 items were selected to form a brief measure (ECR-M16).
Results: Factor analyses of both ECR forms revealed a higher-order factor structure in
which four rst-order factors (Worrying about Relationships, Frustration about Unavailability,
Discomfort with Closeness, Turning Away from Others) loaded onto two second-order factors
tapping Attachment Anxiety and Avoidance. Both ECR forms were reliable and valid.
Conclusion: The ECR-M36 and ECR-M16 are good measures of attachment orientations for
use with medically ill, older populations.
Copyright r 2008 John Wiley & Sons, Ltd.
Keywords: cancer; oncology; psychometrics; attachment; measurement
Introduction
Attachment theory posits that developmental
experiences with key relational gures contribute
to internal working models of self in relation to
others [13]. These internal models manifest in
attachment orientations (secure, anxious, avoidant), which have a lasting impact on relational
motives, cognitions, aect, behavior, and the
quality of social interactions and close relationships across the life span [13]. Attachment anxiety
and avoidance have been identied as the two
continuous dimensions of attachment security,
with securely attached individuals scoring low on
both dimensions [3,4]. Anxiously attached individuals tend to fear abandonment and to worry
about the availability and closeness of others.
Avoidantly attached individuals tend to believe
that they should not depend on others, relying only
on themselves.
There has been growing interest in the contribution of attachment orientations to the ability to
cope with the problems associated with medical
illness [5,6]. In that regard, insecurely attached
individuals (either anxious or avoidant) have been
found to be more likely to report pain and painrelated fear [7], consistent with their tendency to
focus on negative emotional experience [3]. In a
similar vein, Ciechanowski and colleagues [8]
found, in a study of patients with diabetes, that
insecurely attached individuals tended to be more
depressed and that attachment avoidance, in
particular, was associated with poorer communication with medical-care providers, less adherence to
treatment, and worse health outcomes. It has also
been observed that increased dependency needs in
individuals with advanced and progressive disease
may be threatening and trigger a crisis in those with
limitations in their capacity to rely on others [6]. In
research with patients with end-stage cancer,
Measuring attachment security
attachment anxiety and avoidance have been found

to be associated with less social support and more
psychological distress [9].
The goals of the present analyses were to report
on (1) the psychometric properties of a modied
version of the 36-item Experiences in Close
Relationships [4] scale (ECR) for assessing attachment orientations (anxiety, avoidance) to close
others, including both romantic and non-romantic
relationships; and (2) the construction of a brief
version of our modied ECR for use in clinical
research. The short form may have greater utility
because it is less time-consuming and therefore less
burdensome for physically unwell individuals to
complete.
The 36-item ECR [4] is a reliable and valid selfreport measure of adult attachment that has been
used in hundreds of studies (see [3] for an extensive
review). The instrument asks individuals to report
on their thoughts, feelings, and experiences with
romantic partners, and produces scores on the
dimensions of anxious and avoidant attachment. A
number of ECR items ask about experiences with
multiple romantic partners. This may be appropriate for college-age samples, with whom this
measure was developed and validated, and for
whom multiple dating partners may be common.
However, such items may be less applicable to
older individuals who have been married or
committed to the same person for many years.
Although attachment orientations are highly relevant in adult romantic relationships, the exclusive
focus of the ECR on tendencies in romantic
relationships may make it less valid for individuals
who are not currently in a romantic relationship,
who have had one longstanding relationship, or
who have had few total romantic relationships.
Given these considerations, in our research on
patients with advanced gastrointestinal (GI) or lung
cancer, we modied the ECR (ECR-M36) to assess
general attachment orientations in close relationships, rather than in relation to romantic partners.
This has allowed individuals with a wide range of
relational experiences, including those with few or
longstanding intimate relationships to complete the
instrument more easily. Considering attachment
orientations in non-romantic relationships during
the course of severe or life-limiting illness is also
consistent with our interest in understanding the
extent to which disturbances in relatedness to close
friends, family, and medical-care providers can
contribute to psychological distress [6]. Our modied attachment measure may be particularly
appropriate to understand coping in medical
contexts, where health outcomes are inuenced by
the ability of individuals to seek out, trust, and
interact with the multiple persons involved in their
care [5]. We report here on the reliability and
validity of this modied measure in a sample of
advanced cancer patients near the end of life.
491
We also report on the construction and

psychometric properties of a 16-item brief form
of our modied ECR (ECR-M16). To date, only
Wei and colleagues [10] have developed a brief
ECR scale. They were able to shorten the ECR to
12 items without unduly sacricing reliability or
validity. However, their analyses were based on the
original items that assess romantic attachment and
the samples studied consisted of healthy undergraduate students. The present paper is the
rst to report on a brief measure of attachment
orientations to close others (including non-romantic partners), validated in a sample of adult
metastatic cancer patients with a broad range
of ages.
The factor structure of the ECR scale

Brennan et al. [4] constructed the ECR scale from a
pool of 323 items gathered from numerous
measures of romantic attachment orientations in
use at the time. They collected data from over 1000
undergraduate students and calculated 60 subscale
scores based on the items original scales. Anxious
and avoidant dimensions were then identied by
factor analysis. The ECR was created by selecting
36 items (18 tapping each dimension) from the total
pool of items, based on the magnitude of their
correlations with the two dimensions. In their
report, Brennan et al. [4] focused on the factor
analysis of the subscale scores, rather than of the
individual items, although the results of both
analyses were reported. It is important to note
that when factored at the item level, a higher-order
factor structure was apparent: 12 rst-order factors
were initially extracted from the 323 items; when
these 12 factors were subsequently factored, two
higher-order dimensions emerged, which also
corresponded to anxious and avoidant attachment
[4, p. 66].
Subsequent psychometric studies have not
further demonstrated a higher-order factor structure in the ECR or its variations [1014]. The most
relevant ndings come from Wei et al. [10, study 1]
who extracted two factors from the 18 avoidance
items; a separate factor analysis of the 18 anxiety
items yielded three factors. The presence of multiple factors within the anxiety and avoidance
subscales is consistent with a higher-order factor
structure. In the present paper, we explicitly test for
a higher-order structure, since a brief measure
should ideally be constructed so that it reproduces
the factor structure of the full measure.
Main hypotheses
We hypothesized that exploratory and conrmatory factor analyses (CFAs) would show that the
ECR-M36 and ECR-M16 possess a higher-order
factor structure. We also expected that the scales
DOI: 10.1002/pon
492
C. Lo et al.
Table 1. Sample characteristics of individuals providing Time 1

data, Time 2 data, and data at both times
n
M age
(SD age)
Female
Married/
common law
More than
high school education
Major types of cancer
Colorectal
Lung
Pancreas
Hepatobiliary
Time 1
Time 2
Both times
309
60.7
(11.3)
41%
73%
120
60.9
(11.8)
36%
73%
97
59.1
(11.9)
33%
78%
67%
67%
71%
37%
30%
14%
13%
42%
30%
8%
17%
40%
30%
14%
13%
Because only the major types of cancer are listed, those percentages do not sum
to 100%.
would demonstrate internal reliability (internal

consistency), testretest reliability (temporal stability), and construct validity across dierent measurement occasions. To demonstrate construct
validity, attachment anxiety and avoidance were
expected to correlate negatively with self-esteem.
This hypothesis was based on the theoretical
assumption that negative relational histories foster
a negative view of self [15] and on empirical
ndings showing that attachment insecurities are
associated with low self-worth (see [3, Chapter 6]
for an extensive review). Attachment anxiety and
avoidance were also expected to correlate: (1)
negatively with perceived social support, because
insecurely attached individuals, by denition,
experience more diculty in social relations with
others [3]; and (2) positively with depressive
symptoms, because insecurely attached individuals
are less able to protect themselves from the stress of
illness by the expectation or experience of support
[5,6,9].
Method
Construction of the ECR-M36
We modied the 36-item ECR [4] to assess
attachment to close others rather than to romantic
partners only. This was accomplished by substituting, within relevant items, the terms other people
or people with whom I feel close in place of
romantic partner(s); and by adding the instruction that the term other people refers to people
with whom the patient feels close. As in the original
ECR, participants use a 7-point scale (1 disagree
strongly, 7 agree strongly) to rate their agreement
with statements based on their experiences in close
relationships. Anxiety and avoidance scores are
computed by reverse-scoring and averaging releCopyright r 2008 John Wiley & Sons, Ltd.
vant items on each subscale. Higher anxiety and

avoidance scores represent greater attachment
insecurities. Time 1 internal reliabilities for the
anxiety and avoidance subscales were high, Cronbachs alpha 5 0.91 and 0.88, respectively. Time 2
internal reliabilities were the same as Time 1
internal reliabilities.
Participants and procedure

The present study is a secondary analysis of the
Will to Live (WTL) study [16], a longitudinal
investigation of the determinants of psychological
distress in patients with advanced incurable cancer.
The WTL protocol was approved by the University
Health Network Research Ethics Board. Participants were recruited from oncology outpatient
clinics at Princess Margaret Hospital in Toronto,
Canada. Patients were eligible for the study if they
were 18 years of age or older; were suciently
uent in English to give informed consent and
complete self-report questionnaires; and were
diagnosed with Stage IV GI or Stage IIIA, IIIB,
or IV lung cancer.
Exclusion criteria included a diagnosis of carcinoid or neuroendocrine carcinoma, because of the
unusual symptoms associated with those cancers;
and cognitive impairment documented in the
medical chart, identied by their physician, or
demonstrated by a failure to meet the cut-o score
of 20 on the Short Orientation Memory Concentration Test [17] during recruitment. After providing informed consent, patients were given a
questionnaire package to complete in the waiting
room or at home. Participants were assessed
approximately every 2 months until death or study
withdrawal.
The present study analyzed data from the Time 1
or baseline assessment, completed at study entry,
and the assessment that occurred between 4 and 6
months after baseline, which will be referred to as
the Time 2 assessment. It was on these two
occasions that the ECR-M36 was administered to
participants. Because we were interested in the
psychometrics of the ECR-M36, we only analyzed
data from individuals who provided complete
ECR-M36 data. These patients did not dier from
non-completers of the ECR-M36 on any other
measured demographic, psychosocial, or diseaserelated variable. At Time 1, 309 individuals, out of
the 419 who returned an assessment, provided
complete ECR-M36 data. At Time 2, 120 individuals, out of the 185 who returned an assessment,
provided complete ECR-M36 data. In total, 97
individuals provided complete ECR-M36 data at
both times (see Table 1 for sample characteristics).
It is important to note that dierent statistical
analyses focused on dierent time points, and the
sample sizes therefore varied across analyses. For
example, factor analyses of Time 1 data were
DOI: 10.1002/pon
performed on the sample of 309 participants; factor

analyses of Time 2 data were performed on the
sample of 120 participants; and analyses of crosstime correlations (e.g. testretest reliabilities) were
performed on the 97 participants who provided
data at both time points.
Other measures
Self-esteem was assessed using the 10-item Rosenberg Self-Esteem Scale [18] (RSES). Higher scores
indicate higher self-esteem. Internal reliability of
this scale was high in the current study, Cronbachs
alpha 5 0.88 at both times. Perceived social support
was assessed using the Medical Outcomes Study
Social Support Survey [19] (MOS-SSS), a 20-item
scale that asks individuals to rate how much social
support they receive across multiple domains.
Higher scores indicate greater perceived social
support. Internal reliability was high, Cronbachs
alpha 5 0.96 at both times. Depressive symptoms
were assessed using the Beck Depression InventoryII [20] (BDI-II). The BDI-II is a 21-item selfreport measure of depressive symptoms that is
consistent with the Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition, Text
Revision [21] criteria for major depressive disorder.
Higher scores indicate more severe depressive
symptoms. Internal reliability was high, Cronbachs alpha 5 0.90 at Time 1 and 0.89 at Time 2.
For more information about these measures in the
WTL study (e.g. detailed descriptive statistics,
imputation of missing values), see Rodin et al. [16].
Statistical analyses
Analyses were computed with SAS 9.1. To initially
examine the factor structure of the ECR-M36, a
CFA was run on Time 1 data. The CFA tested the
t of a two-factor model in which the 18 items
designed to assess attachment anxiety were indicators of one factor and the 18 items designed to
assess avoidance were indicators of the other
factor. A good tting model is indicated by a
Comparative Fit Index (CFI) greater than 0.90
[22], a Non-Normed Fit Index (NNFI) above 0.90
[22], and a Root Mean Square Error of Approximation (RMSEA) below 0.06 [23]. We predicted
that the two-factor model would not t well if the
data possessed a higher-order factor structure.
Next, a higher-order factor analysis [2427] was
conducted on Time 1 ECR-M36 data. The
procedure began with an exploratory factor analysis with promax rotation to allow the rst-order
factors to be correlated. After extracting four rstorder factors, we then factor analyzed the interfactor correlation matrix to yield the second-order
factors. The second-order factors were varimaxrotated, rather than promax-rotated, to end the
higher-order factoring procedure.
493
When interpreting the meaning of the secondorder factors, Gorsuch [25] advises against examining the rst-order factor loadings on the secondorder factors. The reason is that to interpret the
second-order factors based on their relation to
interpretations of the rst-order factors would
amount to basing interpretations upon interpretations of interpretations [25, p. 245]. The solution is
to post-multiply the rst-order factor pattern
matrix by the second-order factor pattern matrix,
producing a product matrix which is then orthogonally rotated (see [26] for SAS programming
code). This rotated product matrix constitutes the
loadings of the original items on the second-order
factors, and is used to interpret the meaning of the
second-order factors. Although we had no predictions about the rst-order factors that would
emerge from the higher-order factor analysis, we
predicted that two second-order factors corresponding to attachment anxiety and avoidance
would emerge. Note that in our analyses, we did
not specify a single higher-order attachment
security factor because attachment anxiety and
avoidance have been conceptualized and empirically demonstrated to be distinct behavioral
strategies that elicit dierent emotional and relational consequences [3,4,1015].
The items that were the best indicators of higherorder anxiety and avoidance and of the lower-order
factors, as established at Time 1, were selected to
form a brief measure. A CFA then tested the
presence of a higher-order factor structure in the
reduced set of items, based on Time 2 data. For
comparison, a second CFA also tested the presence
of a simple two-factor model (consisting of an
anxiety factor and an avoidance factor) in the
reduced set of items at Time 2. We predicted that
the higher-order model would t Time 2 data well,
whereas the two-factor model would not.
Lastly, we examined the reliability and validity
of the brief anxiety and avoidance subscales.
Internal reliabilities at Time 1 and Time 2 and
testretest reliabilities were calculated for the brief
subscales. Construct validity was examined using
the correlations between attachment insecurities
(anxiety, avoidance), and self-esteem, perceived
social support, and depressive symptoms. Higher
anxiety and avoidance were predicted to correlate
negatively with self-esteem and social support, and
positively with depressive symptoms.
Results
CFA at Time 1
A CFA tested the t of a two-factor model to the
ECR-M36 data at Time 1. The 18 items designed to
assess attachment anxiety were specied as indicators of one factor; the 18 items designed to assess
DOI: 10.1002/pon
494
C. Lo et al.
Table 2. Time 1 item loadings on first-order factors

Loadings
Items
30. I get frustrated when other people are not around as much as I would like
32. I get frustrated if other people are not available when I need them
36. I resent it when people with whom I feel close spend time away from me
24. If I cant get other people to show interest in me, I get upset or angry
28. When Im not involved in a relationship, I feel somewhat anxious and insecure
20. Sometimes I feel that I force other people to show more feeling, more commitment
34. When other people disapprove of me, I feel really bad about myself
18. I need a lot of reassurance that I am loved by people with whom I feel close
12. I often want to merge completely with other people, and this sometimes scares them away
26. I find that other people dont want to get as close as I would like
16. My desire to be very close sometimes scares people away
7. I get uncomfortable when other people want to be very close to me
13. I am nervous when other people get too close to me
17. I try to avoid getting too close to other people
23. I prefer not to be too close to other people
9. I dont feel comfortable opening up to other people
5. Just when other people start to get close to me I find myself pulling away
11. I want to get close to other people, but I keep pulling back
1. I prefer not to show other people how I feel deep down
31. I dont mind asking other people for comfort, advice, or helpa
27. I usually discuss my problems and concerns with people with whom I feel closea
33. It helps to turn to other people in times of needa
35. I turn to other people for many things, including comfort and reassurancea
25. I tell people with whom I feel close just about everythinga
15. I feel comfortable sharing my private thoughts and feelings with other peoplea
19. I find it relatively easy to get close to other peoplea
3. I am very comfortable being close to other peoplea
2. I worry about being abandoned
8. I worry a fair amount about losing people with whom I feel close
4. I worry a lot about my relationships
6. I worry that other people wont care about me as much as I care about them
10. I often wish that other peoples feelings for me were as strong as my feelings for them
14. I worry about being alone
21. I find it difficult to allow myself to depend on other people
22. I do not often worry about being abandoneda
29. I feel comfortable depending on other peoplea
F1
F2
F3
F4
0.84
0.83
0.68
0.58
0.53
0.50
0.46
0.45
0.45
0.43
0.40
0.08
0.17
0.14
0.11
0.00
0.12
0.17
0.12
0.11
0.16
0.07
0.07
0.02
0.12
0.03
0.10
0.06
0.09
0.28
0.21
0.35
0.43
0.04
0.18
0.24
0.18
0.13
0.02
0.01
0.09
0.09
0.13
0.00
0.24
0.31
0.25
0.76
0.75
0.71
0.64
0.63
0.63
0.61
0.43
0.02
0.04
0.03
0.04
0.10
0.13
0.15
0.21
0.02
0.11
0.01
0.32
0.11
0.15
0.21
0.23
0.06
0.09
0.05
0.03
0.02
0.06
0.05
0.02
0.02
0.19
0.02
0.11
0.01
0.05
0.16
0.18
0.18
0.06
0.04
0.20
0.66
0.65
0.62
0.61
0.59
0.51
0.47
0.40
0.01
0.03
0.03
0.06
0.01
0.12
0.05
0.14
0.36
0.01
0.10
0.03
0.04
0.11
0.12
0.02
0.31
0.13
0.09
0.14
0.01
0.12
0.14
0.18
0.05
0.26
0.10
0.06
0.22
0.03
0.07
0.00
0.05
0.05
0.08
0.07
0.68
0.59
0.52
0.43
0.28
0.51
0.07
0.37
0.14
LoadingsX0.40 are in bold. The last five items listed did not loadX0.40 on any factor or loadedX0.40 on more than one factor. Highlighted items were selected for the
brief measure. F1 5 Factor 1, Frustration about Unavailability. F2 5 Factor 2, Discomfort with Closeness. F3 5 Factor 3, Turning Away from Others. F4 5 Factor 4,
Worrying about Relationships.
a
Reverse-scored in the direction of anxiety or avoidance.
avoidance were specied as indicators of the second

factor; and the factors were allowed to correlate.
As predicted, the two-factor solution t poorly,
CFI 5 0.76, NNFI 5 0.74, RMSEA 5 0.077, indicating that there is more item variation than can be
explained by a simple two-factor structure. The
factors were correlated at 0.45.
Exploratory higher-order factor analysis at Time 1

Four correlated factors were initially extracted by
exploratory factor analysis of the 36 items, based
on the eigenvalue41 criterion and scree plot
examination [22]. The four factors explained 90%
of the total variance. The variance explained by
each factor, controlling for the other factors, was
18, 16, 14, and 9%, respectively. The rst-order
factor pattern matrix is shown in Table 2. Most of
the anxiety items loaded highly on Factor 1, which

we labeled as Frustration about Unavailability,
because the highest loadings were associated with
items about the experience of frustration and upset
when close others are not available for support.
Factor 2 consisted of half the avoidance items and
was labeled as Discomfort with Closeness, because
the highest loadings were associated with items
representing discomfort with intimacy and a desire
to pull away from others. Factor 3 consisted of the
reverse-scored avoidance items and was labeled
Turning Away from Others, because the highest
loadings were associated with items assessing the
(lack of) willingness to disclose and rely on others
in times of need. Lastly, Factor 4 was labeled as
Worrying about Relationships and consisted of a
subset of anxiety items about relational worries
(e.g. rejection, separation, abandonment).
DOI: 10.1002/pon
495
Table 3. Correlations between Time 1 first-order factors
F1.
F2.
F3.
F4.
Frustration about Unavailability

Discomfort with Closeness
Turning Away from Others
Worrying about Relationships
Table 5. Time 1 item loadings on second-order factors
F1
F2
F3
F4
0.40
1
0.04
0.38
1
0.47
0.36
0.04
1
Table 4. Time 1 first-order factor loadings on second-order

factors
HF1
F1.
F2.
F3.
F4.
Frustration about Unavailability

Discomfort with Closeness
Turning Away from Others
Worrying about Relationships
0.86
0.54
0.11
0.81
HF2
0.01
0.67
0.93
0.07
LoadingsX0.40 are in bold. HF1 5 Higher-Order Factor 1, Anxiety. HF2 5 Higher-Order Factor 2, Avoidance.
The inter-factor correlation matrix is shown in

Table 3. This correlation matrix was then factored
using principal components analysis with varimax
rotation to yield a two-factor solution, based on
the eigenvalue 41 criterion and scree plot examination [22]. Higher-Order Factor 1 explained 43%
of the variance among the rst-order factors.
Higher-Order Factor 2 explained 33% of the
variance among the rst-order factors. The second-order factor pattern matrix is shown in
Table 4. We caution that this pattern should not
be used to interpret the meaning of the higherorder factors [2427]. However, it is important to
note that Discomfort with Closeness loaded on both
higher-order dimensions. Using Gorsuchs [25]
procedure, a factor pattern matrix was calculated,
which directly related the second-order factors to
the 36 items (see Table 5). Higher-Order Factor 1
was labeled Anxiety because most of the 18 items
designed to assess attachment anxiety loaded on
this factor. Higher-Order Factor 2 was labeled
Avoidance because most of the 18 items designed to
assess attachment avoidance loaded on this factor.
The higher-order structure at Time 1 was consistent with prediction.
The 16-item short form of the modified ECR

(ECR-M16)
We selected 16 items to form a brief instrument.
The number of items was based on the recommendation that each rst-order factor should be
assessed by four items/variables, to optimally
measure a latent factor [22]. The resulting instrument therefore includes eight items measuring
anxiety and eight items measuring avoidance. Items
were selected based on the following criteria: (1) a
high loading (i.e. X0.40) on only one rst-order
factor and only one second-order factor; (2) the
Even (anxious) items

Item
HF1
6
14
4
12
18
8
36
2
26
16
28
30
20
10
32
24
34
22
0.70
0.69
0.65
0.65
0.64
0.62
0.62
0.61
0.61
0.60
0.60
0.60
0.59
0.58
0.56
0.52
0.49
0.31
Odd (avoidant) items

HF2
0.21
0.07
0.08
0.01
0.02
0.11
0.00
0.09
0.21
0.08
0.03
0.02
0.04
0.11
0.04
0.03
0.08
0.01
Item
31
17
25
33
9
23
27
35
15
13
7
19
5
3
1
11
29
21
HF1
HF2
0.00
0.36
0.09
0.04
0.26
0.26
0.00
0.13
0.06
0.44
0.34
0.03
0.43
0.08
0.15
0.55
0.11
0.13
0.65
0.62
0.61
0.61
0.60
0.59
0.58
0.58
0.57
0.55
0.53
0.53
0.51
0.50
0.48
0.40
0.38
0.20
In all versions of the ECR, items meant to assess anxiety are even-numbered;
items meant to assess avoidance are odd-numbered. LoadingsX0.40 are in bold.
HF1 5 Higher-Order Factor 1, Anxiety. HF2 5 Higher-Order Factor 2, Avoidance.
items with the highest loadings on Anxiety and

Avoidance were selected rst; and (3) when items
were tied in the magnitude of their loadings on
Anxiety or Avoidance, the item with the highest
loading on the relevant rst-order factor was
selected. Item selection was straightforward, except
in choosing between items 12 and 18. Item 12
loaded 0.65 on higher-order Anxiety, whereas item
18 loaded 0.64; the items were tied in their loadings
on lower-order Frustration about Unavailability.
Applying our criteria would have meant selecting
item 12, but because this item is double-barreled
(i.e. it is composed of two separate statements), we
selected item 18 instead.
Items 18, 26, 30, and 36 (loading on Frustration
about Unavailability) and items 2, 4, 6, and 8
(loading on Worrying about Relationships) were
selected as the best indicators of higher-order
Anxiety. Items 7, 9, 17, and 23 (loading on
Discomfort with Closeness) and items 25, 27, 31,
and 33 (loading on Turning Away from Others)
were selected as the best indicators of higher-order
Avoidance. These items are highlighted in Table 2.
CFAs at Time 2
Two CFAs were conducted to verify at Time 2 the
higher-order structure identied at Time 1. The
rst CFA tested the 16 selected items for a higherorder factor structure. It is important to note that
Discomfort with Closeness was specied as having
equally weighted paths (i.e. weights of 0.5) to both
Anxiety and Avoidance, as suggested by Time 1
data. Preliminary analyses revealed that it was not
DOI: 10.1002/pon
496
possible to specify Discomfort with Closeness as

being related only to Avoidance, nor was it possible
to freely estimate both paths without encountering
a negative variance parameter for Discomfort with
Closeness in the CFA solution. The second CFA
tested the 16 items for a simple two-factor solution
(i.e. the eight anxiety items specied as indicators
of one factor, the eight avoidance items specied as
indicators of the second factor, the factors were
allowed to correlate). The higher-order model was
predicted to t better than the simple two-factor
model.
The higher-order model t well at Time 2,
CFI 5 0.95, NNFI 5 0.94, RMSEA 5 0.056, and
an examination of the modication indices and
residual covariance matrices did not reveal any
problematic local item dependencies. The standardized parameter estimates are depicted in Figure 1.
Note that item 25 had a rather low path coecient.
C. Lo et al.
We tried replacing item 25 with item 35, the next

best candidate, but the model t was poorer and so
item 25 was kept. We also experimented with
dierent weighting schemes for the paths relating
Discomfort to Avoidance and Anxiety (e.g. 0.6 to
Avoidance and 0.4 to Anxiety), but these alternative
schemes yielded slightly poorer tting models or a
negative variance parameter for Discomfort. Finally, as predicted, the simple two-factor model t
poorly, CFI 5 0.79, NNFI 5 0.75, RMSEA 5 0.11,
indicating that a higher-order factor structure is
necessary to account for the covariation among
items.
Reliability and validity of the ECR-M16

Time 1 internal reliabilities were good for the brief
anxiety and avoidance subscales, Cronbachs alpha 5 0.84 and 0.83, respectively, as were Time 2
Figure 1. Standardized parameter estimates for the confirmatory higher-order factor model at Time 2. D1-D4 are disturbance
terms. Error terms for items are not depicted

DOI: 10.1002/pon
497
Table 6. Correlations across time for the full and brief

attachment subscales
Time
T1
T1
T1
T1
Scale
Anx-18
Avo-18
Anx-8
Avo-8
T2
Anx-18
T2
Avo-18
0.81
0.28
0.32
0.76
T2
Anx-8
T2
Avo-8
0.82
0.26
0.28
0.73
Table 7. Correlations between the full and brief attachment

subscales, self-esteem, social support and depressive symptoms
at Time 1 and Time 2
Time 1
Anx-8
Avo-8
RSES
MOS-SSS
BDI-II
Anx-18
0.96
0.29
Avo-18
0.32
0.94
0.36
0.35
0.43
0.33
0.42
0.21
Anx-18
0.95
0.41
Avo-18
0.46
0.94
Anx-8
0.36
0.34
0.42
Avo-8
0.33
0.40
0.19
Anx-8
0.15
0.28
0.18
Avo-8
0.25
0.55
0.25
Time 2
Testretest reliabilities are in bold. T1 5 Time 1. T2 5 Time 2. Anx-18 5 18-item
anxiety subscale. Avo-18 5 18-item avoidance subscale. Anx-8 5 8-item anxiety
subscale. Avo-8 5 8-item avoidance subscale.
po0.05; **po0.0001.
internal reliabilities, Cronbachs alphas 5 0.86 and

0.81, respectively. The testretest reliabilities were
also good for the brief and full subscales (see
Table 6 for these and other cross-time correlations).
Table 7 shows Pearson correlations between the
full and brief subscales within each assessment
occasion. The full and brief anxiety subscales
correlated highly at Time 1 and at Time 2, as was
true of the brief and full avoidance subscales at
both times. Concerning construct validity, Table 7
also describes Pearson correlations between the
attachment subscales (full and brief) and selfesteem, perceived social support, and depressive
symptoms within each measurement occasion. All
signicant correlations were in the predicted
direction. At Time 1, self-esteem showed a signicant negative association with anxiety and
avoidance. At Time 2, self-esteem showed a
signicant negative association with avoidance.
At Time 1 and at Time 2, anxiety and avoidance
showed signicant negative associations with social
support and signicant positive associations with
depressive symptoms. See Appendix A for the
ECR-M16.
Discussion
We have reported on the psychometrics of a
modied version of the 36-item ECR (ECR-M36)
for measuring attachment orientations to close
others (including non-romantic partners) in patients with advanced incurable cancer. We have
also constructed a reliable and valid 16-item
version of the modied ECR (ECR-M16) to
facilitate the study of attachment in medically ill
populations.
A higher-order factor structure was identied in
the ECR-M36 at Time 1, and was replicated in the
ECR-M16 at Time 2. This higher-order structure is
consistent with the factor structure of the 323 items
out of which the original ECR was constructed [4,
Anx-8
Avo-8
RSES
MOS-SSS
BDI-II
0.16
0.25
0.21
0.29
0.56
0.31
Anx-18 5 18-item anxiety subscale. Avo-18 5 18-item avoidance subscale. Anx8 5 8-item anxiety subscale. Avo-8 5 8-item avoidance subscale. RSES 5 selfesteem. MOS-SSS 5 social support. BDI-II 5 depressive symptoms.
po0.05; **po0.0001.
p. 66]. In the present study, we found four rstorder factors, representing Frustration about Unavailability, Worrying about Relationships, Discomfort with Closeness, and Turning Away from Others.
We note that the Turning Away factor was
composed of the positively keyed items of the
avoidance subscale. Such clustering is common in
self-report scales [28], and it is a limitation of the
ECR that its subscales do not have a balanced
number of positively keyed and negatively keyed
items. A factor analysis of the four rst-order
factors revealed two second-order factors identied
as Attachment Anxiety and Avoidance, given that
items meant to assess anxiety loaded on Anxiety
and items meant to measure avoidance loaded on
Avoidance.
Of theoretical importance is the nding that the
rst-order factor Discomfort with Closeness was
related to both Anxiety and Avoidance. The reasons
behind the double-loading of Discomfort were
initially unclear, based on Time 1 analyses. Of the
three items that make up the Discomfort factor,
three items were found to load highly (i.e. X0.40)
on both Anxiety and Avoidance. It was therefore
possible that the double-loading of Discomfort was
due to just those three items. When selecting the 16
items for the Time 2 factor analyses, we were
careful to choose items that did not double-load on
both Anxiety and Avoidance. The four selected
Discomfort items loaded highly on only Avoidance,
although we acknowledge that their loadings on
Anxiety are not inconsequential, ranging from 0.26
to 0.36. Despite the removal of the three problematic items, it was evident from the Time 2 CFA
that Discomfort with Closeness still should be
specied as related to both Anxiety and Avoidance.
DOI: 10.1002/pon
498
Conceptually, the double-loading of Discomfort on

the higher-order attachment dimensions suggests
that both attachment anxiety and avoidance tap
some discomfort with the experience of intimacy
and closeness [3,29]. While avoidant individuals
withdraw from others in response to their discomfort, consistent with their emphasis on independence, anxious individuals attempt to pull
others even closer, consistent with their fear of
abandonment [30].
The ECR-M36 and ECR-M16 showed good
psychometric properties. Both measures were
reliable. The measures also showed small to
moderate correlations with self-esteem, social
support, and depressive symptoms, which is
acceptable evidence of construct validity, given
the diversity of the constructs assessed. Future
research may seek more direct validation by
comparing our modied measures against other
measures of attachment.
We agree with Wei et al. [10] that the ECR can
be substantially shortened. However, the items
selected for our short form diered from the items
they selected, likely because of dierences in our
respective populations and methodologies. Wei et
al. [10] studied college-age samples, whereas we
studied much older individuals suering from
advanced cancer. Wei et al. [10] retained the
original ECR items assessing attachment orientations within romantic relationships, whereas we
used modied items assessing attachment to close
others. Finally, Wei et al. [10] did not look for a
higher-order factor structure, whereas we did.
Three limitations of the present study deserve
mention. The rst is that our modied scales, like
the original ECR, do not have a balanced number
of positively keyed and negatively keyed items
across their subscales. Future scale development
may introduce new positively keyed anxiety items,
or may replace all positively keyed avoidance items
with new negatively keyed items. The second
limitation is that this is a secondary analysis,
thereby limiting the specic measures that are
available for the validation. The third limitation is
that our selection of the items for inclusion in the
brief measure was in some cases based on small
dierences between the loading of a selected item
and an unselected item. Although we chose the
items with the higher loading, some of the items
that were close contenders for selection may be
equally good indicators.
In conclusion, we have developed modied
ECR scales that may make the measurement of
attachment more feasible for patients of diverse
ages across a variety of medical settings. These
measures assess general attachment orientations
to close others and therefore may be more suitable
for medically ill, older individuals. The briefer
16-item scale may have an advantage in studies
with physically unwell individuals for whom
C. Lo et al.
study burden should be minimized. The information generated by these measures may also be
of clinical value. Greater awareness of patient
attachment fears and concerns may help clinicians
to intervene more sensitively and to be more
responsive to the specic support needs that
are activated by illness [31]. Clinicians may
intervene by strengthening patient attachment
bonds to close others [31]. Supportive interventions
may also be tailored based on attachment orientations to help maximize their treatment ecacy
[6,32].
Acknowledgements
This study was supported by a grant from the Canadian
Institutes of Health Research (CIHR MOP-62861; G.R.)
and by the Edith Kirchmann Fellowship at Princess
Margaret Hospital (C. L.). The authors gratefully acknowledge this support. Thanks also go to the Behavioural
Sciences and Health Research Manuscript Review Seminar
for their help with earlier drafts.
Appendix A
Experiences in Close Relationships Scale
Modified Short Form (ECR-M16)
The following statements concern how you feel in close
relationships with others. In the following statements the
term other people refers to people with whom you feel
close. Using the rating scale, indicate how much you agree
or disagree with each statement by circling one (1) number
per line.
1
2
3
4
5
6
7
Disagree yyy. yyy. Neutral yyy. yyy. Agree
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
I get uncomfortable when other people want to be very close

to me.
I worry about being abandoned.
I tell people with whom I feel close just about everything.
I need a lot of reassurance that I am loved by people with
whom I feel close.
I dont feel comfortable opening up to other people.
I worry a lot about my relationships.
I usually discuss my problems and concerns with people with
whom I feel close.
I find that other people dont want to get as close as I would like.
I try to avoid getting too close to other people.
I worry that other people wont care about me as much as
I care about them.
I dont mind asking other people for comfort, advice, or help.
I get frustrated when other people are not around as much as
I would like.
I prefer not to be too close to other people.
I worry a fair amount about losing people with whom I feel close.
It helps to turn to other people in times of need.
I resent it when people with whom I feel close spend time away
from me.
Even-numbered items measure attachment anxiety. Odd-numbered items

measure avoidance. Items 3, 7, 11, and 15 are reverse-scored.

DOI: 10.1002/pon
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Psycho-Oncology

Psycho-Oncology 18: 490499 (2009)