Mending the Eating Disorder Fence: Neither This nor That

Research in Attachment Theory provides evidence for contributing factors in EDs

Posted Jun 28, 2016

Research on Attachment Theory in understanding causal factors in eating disorders is increasingly available, outcomes of studies found valid and treatment protocols stemming from the research are respected as “evidence” based.  

Although specific treatment recommendations remain tailored to the needs of each patient individually, inclusion of the relational contributions resulting from

Attachment Theory research give the practitioner and patient more opportunity for understanding and treating the complexity of eating disorders.  The development of psychological conditions where symptoms act as a substitute for connection i.e. eating disorders, sexual addiction, substance use make increasing sense to people struggling to understand how and why their loved one could develop symptoms and behaviors that are self-defeating and self-destructive.  For some, understanding an eating disorder from this perspective is a significant ‘light bulb’ moment.  

I find myself with almost regularity in my blog posts providing the caveat that eating disorder etiology and treatment are as unique and specific as is the person who develops one.  There is no one cause and no one size fits all treatment approach.

Biologic pre-determining factors like anxiety and depression and traits like perfectionism are common in patients with eating disorders.  The motivational factors, whether biologic, psychological and/or relational, are up for vigorous and scholarly discussion and continued research.  No one can say with certainty for all sufferers that their anxiety and depression have roots in biology or that their perfectionism is an inherited trait.   Conversely, no one can say that eating disorders are  based on completely psychological, relational and environmental factors without the likely contributions of biological pre-determinants.

Evaluation of the current research in eating disorders and attachment issues in adolescents by Gander, et al, “Eating disorders in adolescence:  attachment issues from a developmental perspective,” (Frontiers in Psychology. 2015) summarized their findings as follows:

“The most striking result that emerges from the latest state of narrative-based research is the high prevalence of unresolved attachment status in adolescent patients and their mothers. Only a small number of studies included fathers and they show that patients feel more alienated from them and they describe them as less caring and more controlling.  Furthermore, recent studies demonstrate that adolescents with unresolved attachment representation have a greater rate of co-morbid disorders like PD and depression and higher ED symptom severity.”  

Treatment protocols therefore need to be tailored to patients with attachment issues.  

An earlier study by Tasca.”Implications of attachment theory and research for the assessment and treatment of eating disorders,” (Psychotherapy. September 2011) revealed the following regarding treatment protocols:   “Those with attachment-associated insecurities are likely to be the least to benefit from current symptom-focused therapies.

Since treatment approaches are designed based on research and theory,  then implementing specific strategies with patients ought to be fueled by knowing the research and understanding the theories.  In support or perhaps, defense, of the theoretical orientations that focus on psychology and relationships, I return to delineating some of the basic tenets of Attachment Theory for consideration in understanding and treating eating disorders.  

Attachment theory is based on the belief that bonding early in childhood affects one’s self-esteem and relationships throughout life. These bonds, or attachments, not only give children the emotional stability needed to weather the storms of life, they also provide a basis for handling their emotions which, as we all know, are sometimes difficult to cope with. Family attachments provide a model on which other relationships will be founded for the rest of their lives. If a child feels safe in her attachment, then she feels safe to explore her world — both her internal world of fantasies, dreams, wishes, wants, and intuition, and her external world of life experiences and interpersonal relationships.

The reason children and adults throughout the lifespan seek these attachments has been debated in psychological circles for more than a century. When John Bowlby, the founder of Attachment Theory, trained to be a psychoanalyst, two schools of psychological thought prevailed. On one side of the argument were those influenced by Sigmund Freud. The other side would eventually be comprised of Bowlby himself as well as people like D.W. Winnicott, W.R.D. Fairbairn, and Margaret Mahler.

Psychoanalysts influenced by Freud believed that children seek attachment not to feel connected, but in order to not feel anxious. For example, if a child didn’t receive the level of affection from her parent that she desired or if she otherwise wasn’t getting her needs met, she would create an “attachment” to overcome the dread that might arise. This bond would soothe the child’s anxious mind and would create an emotional tether that would help insure she got what she wanted from her parents in the future.

While Bowlby initially agreed, he quickly began to realize that this model of attachment had serious shortcomings. Freud’s theories are founded upon the belief that human beings are driven by aggressive and pleasure-seeking instincts and that they seek socially acceptable ways to express and discharge these energies, or “drives” as Freud called them. Going back to the example above, when the child didn’t get what she wanted, she sought an attachment that would not only salve her painful anxiety but would also help her get what she desired in the future. (It’s interesting to note that Freud himself seemed to relent on this position in his later writing and began to consider the possibility that feeling close to others was primary, not just a vehicle for getting one’s needs met.)

Bowlby began to ask questions: What if human beings aren’t driven by the need to gratify “instinctive impulses?” What if they aren’t seeking ways to discharge their drives? What if attachment is fundamental to human nature, not the outcome of an anxious mind? And what would happen to children who didn’t have this fundamental need met? What would happen if a child didn’t have an experience of bonding and attachment with a caring adult figure?

To begin answering some of these questions, Bowlby’s early work focused on children separated from parents through death, divorce, or illness. In a key finding, he studied juvenile delinquents who were raised in institutions from the age of seven months. He found that they were impaired in motor and language development and had difficulty forming stable relationships. They also experienced intense feelings of pain, sadness, and anguish that did not diminish in adulthood. This led Bowlby to believe that a child who was separated from her caregivers for a prolonged period during the first five years of her life would develop character problems later on.

If this were the case, i.e. if prolonged separation from a caregiver led to problems with character development, it would appear that attachment is not created to satisfy instinctive, pleasurable, or aggressive needs or impulses but is rather an inherent psychological need of its own. It is fundamental to the healthy and natural development of human beings and their social relationships.

This is the belief that Bowlby and other post-Freudians adopted. These “relational theorists” did not believe as Freud did that aggressive responses like anger were solely innate. They believed also that anger and other emotional states were a consequence of an interpersonal interaction — a child experiences anger when she is frustrated, provoked, or not gratified, i.e., when she does not have a healthy attachment with the people in her life.

Although the ideas put forth by each relational theorist differed slightly, their views were the same on one central point — attachment to a caregiver is the cornerstone of a child’s sense of stability, safety, and self-esteem. 

Two main precepts form the core of Bowlby’s work: 

1.  The bond between parents and children is extremely important.

2.  Children need a secure and stable environment that supports the understanding that separation and loss are inevitable consequences of attachment.

The first is an obvious outcome of the concept that attachment is a fundamental human need. If it is, then it’s obvious that the bond between parent and child (or caretaker and child) is of the utmost importance. The second point is a little less clear on the surface. Why would it be necessary to present a stable environment that supports the understanding that separation and loss are inevitable?

In a nutshell, the integration of ALL human emotions was a foundational element in Bowlby’s work, and I believe it is essential in the treatment of eating disorders.  When the going gets tough, the tough don’t get going, unless they have support and permission for feeling bad.  Loss and separation are integrated as normal; therefore attachment is possible because the pain of loss can be experientially and emotionally tolerated.  

For a fuller explanation of the concept of Loss and Separation, I invite you to read a previous Blog post on separation and loss, "The Importance of Accepting Painful Emotions." (October 31, 2015. Psychology Today.) 

In my next blog, I shall address some of the treatment modalities available for the treatment of eating disorders from an Attachment Theory perspective.

Judy Scheel, Ph.D., LCSW