Implementing Attachment Theory in Treating Eating Disorders

Treatment strategies a.k.a. how to do it

Posted Aug 12, 2016

The current research in the treatment of eating disorders continues to shape and enhance our theoretical understanding and impacts how we approach treatment.

Some clinicians and researchers assert that it does not matter how patients arrived at their disorder, but rather what is necessary to help them recover.  Focusing on what caused a particular individual’s eating disorder is not relevant certainly when medical stabilization and return to normal weight range are paramount.   My inclination remains, however, that uncovering causation enables the individual to understand motivations (what purposes the eating disorder and its symptoms serve in someone’s life.)   Knowing the factors driving the proverbial bus can support informed decisions about what is necessary in maintaining recovery and long term health and well-being.  

Patients with eating disorders have profound interpersonal and psychological issues.  They are indeed a vulnerable population from a mental health standpoint.   Most researchers, clinicians, patients and family members find agreement in accepting that treatment and recovery are a long process.   Research repeatedly affirms that pre or co-existing anxiety and/or depression co-occur with eating disorders.  Research remains limited in qualitative studies which explore early childhood experiences and relationships and their contributions to setting the stage for eating disorder development later on in life.  

Most clinicians and researchers tend to agree that patients with eating disorders are highly susceptible to criticism, shame and fear being or behaving imperfectly.   They tend to be highly competitive and mistrustful; often these qualities play off each other.  Many in the psychodynamic and psychoanalytic camps would agree that these fragile interpersonal qualities are the outcrop of childhood attachment experiences and their intensity is compounded as a child grows throughout life.  Eating disorders therefore are ‘natural’ consequences as they attempt on the one hand to correct the vulnerable states  through perfection and fitting in to the culture as well as are the means in which to punish the individual for being imperfect i.e. having vulnerabilities.  

Patients with eating disorders are on guard.  Their relationships are often highly charged and mistrustful.    

Understanding the tenants of Attachment Theory and finding ways to operationalize the theory in providing solid and appropriate treatment is useful regardless of how the issues got there.  

In more than 20 years in treating patients with eating disorders utilizing Attachment Theory has been invaluable because it respects the relationship between the patient and therapist as a significant vehicle for recovery.  Therapeutically creating an environment where the patient feels safe and understood, enables trust to build.  With trust comes more revelation and an opportunity to deal with negative emotion and confront and discuss self-destructive behavior, shameful thoughts and conflicted relationships.  Compassion, forgiveness and empathy therefore have an opportunity to be experienced and shared.   Attachment Theory provides a natural framework in the relationship between therapist and patient.   Utilization of this approach is not recommended for the therapist who is not comfortable with a deeper level of intensity, emotion and connection to their patients.  

I have a bias.

When I was in graduate school getting my doctorate, the University required that doctoral students take a course outside of the university dealing with the subject matter of their proposed dissertation.  I took a course in the clinical Psychology department dealing with character pathology and personality disorders.   Among the first questions the professor asked was how many of us in the room had ever seen a therapist.   There were 15 students in the class.  Three of us raised our hands.  The professor and I were two of the three.  

Know thyself.

There is an old expression which states that you can only take your patients emotionally as far as you have come yourself.  Practicing from an Attachment Theory perspective requires the therapist to have a solid handle on their own emotions and psychology.   If a therapist is uncomfortable with feelings of anger, or cannot tolerate their patients’ dependency, or is uncomfortable with discussing sex and sexuality, then Attachment Theory is not likely a comfortable lens from which practice.  If a therapist has not confronted their own competitive issues or lacks compassion and empathy creating a safe place for the truth to be told is hampered.    

There are other evidence based treatment approaches that are available that help patients.  These approaches are routinely utilized by eating disorder therapists.   Whether they are truly more efficacious is yet to be determined.    Research outcomes differ and studies are contradictory often due to a particular study’s limitations (usually based on low sample size) or some other subjective data that is difficult to quantify. 

Operationalizing Attachment Theory

Wylie and Turner operationalized strategies for therapists to utilize when treating eating disorder patients from an Attachment Theory perspective.  (Attachment-Oriented Therapists Live by Four Strategies for Working Through Attachment Theory and its Associated Disorders. 12/26/2013. Psychotherapy Networker.)

The authors highlight some of the significant components of Attachment Theory and the therapeutic relationship.  Insecure, avoidant, ambivalent or disorganized early attachment experiences influence later psychological  and relational development.  These experiences can become repeated throughout life, through choices in adult relationships,  and can have the same recurring effect leaving the now adult no better equipped to handle relationships or emotions.   

Challenges to  self-worth and self-esteem are often markers of those with eating disorders.  Symptoms i.e. relentless pursuit of thinness or body perfection represent the effort to both feel better and as further punishment for feeling not good enough.  

The authors assert, “The right brain/limbic (unconscious, emotional, intuitive) interaction of the psychotherapist and client is more important than cognitive or behavioral suggestions from the therapist; the psychotherapist's emotionally charged verbal and nonverbal, psychobiological attunement to the client and to his/her own internal triggers is critical to effective therapy.”

In other words, the relationship between patient and therapist are paramount in treatment and recovery as the attachment patterns developed in childhood are contemporarily unavoidable and necessary to be played out in psychotherapy.  Scenarios, sometimes called ‘reparative enactments’ are repetitions and reminders of past experiences as these scenarios are replayed in vivo in therapy and are essential to healing and recovery.    This gives the therapist and patient an opportunity to observe and reflect and facilitate repair both in the therapeutic situation and in relationships going forward.  The person learns how to stop, observe, listen, reflect and communicate differently towards the goal of maintaining integrity in all important relationships.  

The therapist needs to be acutely and keenly aware of transference and counter transferential issues.  ( Eating disorder patients are highly triggering for even the most seasoned and adroit therapist.  and some patients will terminate treatment precipitously or pre-maturely no matter how skilled the therapist.  

Quantifying Qualitative States in Therapy:   How to “do” Attachment Theory.

Other therapeutic approaches, like CBT, are very useful in providing patients with tools to change their behaviors, reduce symptoms and decrease negative and irrational thoughts.  Patients, families and even therapists like to take action.  We like to do things.    Utilizing the intensity and simplicity of the therapeutic relationship as the change agent confronts and challenges the belief that we must do in order to get.   Being and experiencing in vivo in the therapeutic relationship, from an Attachment Theory perspective, provides the opportunity for recovery.  

Therapeutic Steps - How to “do” Attachment Theory

Below are a few strategies to utilize.  

1.  Refrain from criticism, blame, or judgment. 

All therapists tend to agree and have committed their professional lives in the acceptance that human motivation, emotions and behaviors are complex.  Judging, criticizing and blaming are overall wholly inappropriate and  ultimately self-serving.   Though it’s easy and sometimes attractive to criticize your patient’s self-destructive behavior or the family’s behavior, particularly when families are under stress, maintain the position that the behavior is self-destructive yet has meaning to the patient.  It is the meaning that the behavior has that is of importance.  In this way, the patient becomes a participant with you as you both are working to understand.  The therapist’s goal is to enlist the patient as a partner in the therapeutic relationship while maintaining professionalism.   The therapist is unabashedly called upon to inject expertise and thoughts.  

For example:  
Therapist:  “I have expertise and training to help you.  Your job is to be honest.  Mine is to accept, understand and help you figure out what you need to be happy and healthy.  We can be partners in this.”  

Embedded in this simple and somewhat 'obvious' statement is that the patient is safe and can grow.  The therapist is attempting right from the beginning of treatment to circumvent the creation therefore of the patient forming an ambivalent, anxious or avoidant attachment.  

2.  Honestly express empathy, compassion, and understanding. Empathy and compassion are the cornerstones to trust.  And it has to be authentic. Patients will see right through any disingenuous attempts. 

For example:
Therapist:  “I am sure that it has likely been very difficult for you to truly be or to believe that you are the round peg in your family’s square whole.  Eating disorders flourish often in families where a child grows up with a keen sensitivity or does not feel that she meets or fulfills the family’s norm or expectations.  There is nothing you need to do except be yourself.  It is my job to understand you, not for you to please me.  We will likely have some bumps together.  When these bumps occur it will provide us opportunities to examine what occurred, what parts are appropriate for each of us to own, how to communicate and be understood so we can move on together.  It will be a good thing when we hit these bumps.”  

Embedded in this statement is the permission to not be perfect and to convey that it is the therapist’s job to understand and accept the patient, not the other way around.

Through an Attachment Theory lens, the implication is that the patient ought not fear rejection.  The patient is safe to proceed.  If the patient truly knows she is safe, then her attachment to the therapist can without ambivalence, anxiety or need to avoid the therapist and therapy.  Patients who routinely withdraw from therapy create a difficult and interesting scenario.  Understanding and teaching the patient about ambivalent, avoidant or insecure attachment  are sometimes key strategies in helping the patient feel safe to so that premature termination can be avoided.   Sometimes the patient cannot or is not ready to commit to the relationship.  Respecting the patient for leaving hopefully will maintain the safety so that the patient can return. Giving up the symptom can be scary or the patient needs to continue to keep the therapist at bay.  

3. Take responsibility for your part when errors occur, but do not subject yourself to being devalued or accept inappropriate criticism or volatility.  Patients with eating disorders tend to be hyperaware and on guard.  The slightest mishap by the therapist can cause a significant pitfall, but hopeful opportunity for growth.  

For Example:  
Therapist:  “I think I forgot something we were talking about last week which I noticed at the beginning of the session that you did bring up and I ignored.  I am noticing now that you have become very quiet.  Is this because you have feelings about the fact that I forgot?”

Being comfortable with Attachment Theory will enable successful utilization of its tenents in treatment.  The  theory enlists the therapist’s creativity.   Armed with knowledge of eating disorders and respect for the emotional, relational and psychological issues that confront patients,  the therapist who is suited and employs Attachment Theory in their work can provide a healing opportunity for patients.  

Next Blog will discuss how to operationalize trust in treatment.

Judy Scheel, Ph.D., LCSW