All resourcesAttachment narrative therapy: integrating ideas from narrative and attachment theory in systemic family therapy with eating disorders
Rudi Dallos
This paper proposes that recent developments in attachment theory, especially the move to the study of representations, offers some helpful new directions for systemic family therapy. Some of the findings of a close association between early attachment experiences and the coherence of the narratives are reviewed. It is suggested that this offers a useful link for systemic approaches in showing how early interactions in families promote not only particular emotional attachment patterns, but also shape the content and style of the narratives that are formed. These implications are then explored in the context of work with anorexia nervosa. It is suggested that commonly observed patterns, such as avoidance of conflict and apparent difficulties in discussing relationships and feelings, is consistent with transgenerational experiences of insecure/avoidant attachments. Some implications for systemic therapy with families are outlined and an illustrative case study is offered.
Introduction
This paper considers the contributions that attachment and narrative theories and therapies can offer to our understanding of the development and treatment of problems, with particular reference to eating disorders. It also invites readers to think about some potential links between more recent ideas from attachment theory which discuss how narratives develop in families with ideas from narrative therapies. At the outset these ideas may appear to be poles apart. However, it will be argued that there are important points of connection.
Narrative approaches
Drawing extensively from social constructionist theory, narrative therapies emphasize, for example, how problems in families can be seen to arise from ‘problem-saturated’ conversation (Anderson et al., 1986). Similarly, White and Epston (1990) describe how pathologizing stories may come to dominate and restrict people’s potential avenues of action. These stories or narratives are fuelled by the underlying beliefs held by a family (Dallos, 1996). A major contribution of narrative approaches has been to locate these stories not simply as internal to the family but as drawn from the pool of culturally shared beliefs. For example, particularly in Western societies, there may be seen to be a dominant narrative that distressed states or experiences are a result of inherent personality flaws, organic deficits or biologically inherited tendencies. Family members and others may come to describe the young person in terms of pathologizing and totalizing language as seen, for example, when people are referred to as ‘anorexics’ or ‘bulimics’. Such terms (as in the above account) may become internalized, and over time come to shape and eventually consume the whole of a person’s identity to the point where aspects of their lives, other than that related to problems of food, become marginalized. In families some of the processes whereby this occurs have been described as ‘problem-saturated’ conversations (Anderson et al., 1986). As a difficulty starts to develop, the focus of the family conversation may move towards a ‘pathway to pathology’ in which the talk shifts to an identification of problems to the exclusion of any talk which may recognize exceptions and competencies (Eron and Lund, 1993; Dallos and Hamilton-Brown, 1999). A central ingredient of narrative therapies is to help people to resist this process by ‘externalizing’ problems, rather than capitulating to the problem by accepting it as an indication of an inherent weakness. People are encouraged to resist the problem by seeing it as external to them, something that has entered their lives as an unwelcome visitor.
Individuals and family members are invited to consider ways in which they can work together to resist the problems to gather strength together. Such an approach is particularly pertinent to eating disorders in the light of the powerful processes of ‘body fascism’– the pressures on women to conform to culturally valued ideas of beauty as slim youthfulness. So far so good. However, for many of us with a deep commitment to social constructionist ideas and a great affection for narrative approaches, using these ideas is not quite so straightforward. For years I have wondered whether there was something wrong with myself, with my skills as a therapist, since I had great difficulty in helping families where anorexia was the presenting problem, in engaging in conversations about their difficulties, their feelings, the impact of the problems on their relationships and vice versa. As I started to share this secret and sense of shame at my shortcomings with other colleagues it produced similar admissions. Moreover, as I explored the literature on eating disorders I began to see that many practitioners reported similar experiences. This started to suggest that perhaps there was something about the willingness or the ability in such families to engage in such conversations. These were difficult thoughts to have because I was aware that it might seem that we were returning to the ‘bad old days’ (first order) of typologizing families or looking for ‘deficits’. I tried to suspend my antagonism and shame about such first-order thinking and to ask some awkward questions:
Is it possible that there is some commonality in families with anorexia? Is it possible that part of this is that they are more unwilling or anxious about engaging in such conversations than other families, Is it possible that they have some difficulty, possibly a cognitive one, in engaging in such conversations? Two strands of research and theory offer some potential answers to these questions. First, there is an increasing body of research on the development of narratives in children (McCabe and Peterson, 1991; Baerger and McAdams, 1999; Habermas and Bluck, 2000). This suggests that the ability to develop stories about one’s life is a sophisticated ‘skill’ which is shaped by the ways in which parents talk to children such that the ability can be facilitated or retarded. Second, this connects with the evidence from attachment theory that the emotional context of the family is an important ingredient in shaping the nature of the kinds of conversations that occur (Main et al., 1985; Fonagy et al., 1991). It is helpful to take a brief look at how attachment theory with its apparent emphasis on biologically based propositions has come to offer some useful ideas about narrative processes.
Attachment theory
A fundamental proposition of attachment theory is that a young infant has an evolutionary based need to become attached to its parent in order to enhance its chances of survival. In systemic terms the child and caretaker maintain a protective process – when the child engages in exploration in the environment, she may respond to threat by seeking security which may activate care-giving and protection. When the threat is resolved the child returns to exploration from a secure base. This interactive process has been described in terms of ‘attachment’, ‘bonding’ or ‘imprinting’.
Translated to family processes this means that infants require the consistent and affectionate presence of their parents in order for a secure attachment to occur (Bowlby, 1969). The work of Ainsworth et al. (1978, 1989) has illustrated in a series of studies, especially through the ‘Strange Situation’ (an observational experimental situation where the mother leaves the infant temporarily), that on reunion infants exhibit one of four main patterns of behaviour described as secure, avoidant, ambivalent and disorganized attach- ment styles. Mothers in the Strange Situation studies were seen to differ in how attuned they were to their babies’ needs while engaged in play with them prior to the period of separations. For example, mothers of infants who showed secure patterns on reunion appeared to be more attuned and synchronized to their children’s actions and
emotional responses. In contrast, mothers of infants who acted in insecure patterns on reunion were characteristically either more distracted and less attuned to their child or less predictably available (Ainsworth et al., 1978). Attachment theory and internal representations Bowlby (1969) emphasized that the accumulation of early experiences becomes internally represented for the infant as a system of enduring emotionally toned beliefs and expectations about relationships – the child’s ‘attachment model’. The evidence from the Strange Situation studies suggests that the infants appeared to have learned a set of expectations or a ‘working model’ regarding their mothers’ responses. Secure attachment strategy. Infants who consistently experience the parent as available appear to develop a representation of the carer as these when needed and an ability to deal with threat and distress. This means that once contact between parent and child is again resumed the child is able to quickly resume exploration, play and other activities.
Insecure attachment strategies. If the child repeatedly experiences the parent as unavailable or insensitive, then the child is likely to remain in a state of arousal and anxiety. The child is in a position of needing to continue to monitor if the parent will become available and also to develop some alternative ways of coping with unmet needs. The two key strategies that enable this to happen are avoidance and preoccupation.
This is seen again to lead to corresponding internal representations and, along with them, different coping strategies which vary according to attachment pattern:
Avoidant pattern – if the child’s experience is that painful rebuffs may occur when she tries to gain closeness, she may try to evolve ways of distracting herself from her need for attachments. The child is therefore engaged in a continual effort to distract herself from her needs by denying them and attempting to focus on other aspects of her situation and experience.
Ambivalent pattern – if the child’s experience is of inconsistent responses from the parent (because the parent is preoccupied) then an attempted strategy may be to become hyper-vigilant so as to maximize the possibility of any attention and care as soon as it appears to be available. This strategy may be associated with decreased exploration and play and excessive focus and concern with the parent, or even anger. Typically this can also involve a clingy style in which the child may attempt to coerce a response from the parent.
Disorganized pattern – if the child’s experience is that responses are extremely inconsistent, threatening or dangerous then she may engage in erratic or even bizarre behaviour, for example, by freezing, self-harming or behaviour which apparently lacks any sense of organization. Importantly, all the strategies imply that attachment needs continue to occupy a large part of the child’s thinking and experience (Kobak and Cole, 1994). In effect both types of strategies leave the child distracted by attachments and less available to engage in other activities. In particular both are more likely to lead to the child being
in a sense stuck inside these loops of continually striving to avoid or gain care. Arguably the child is also more likely to see their relationship in a linear way as opposed to being able to step outside their relationship. In contrast, in a secure attachment style the child is not distracted by continually thinking about the attachment but is able to engage in more communication with the parent, express her feelings, and develop different ways of becoming close and also the possibility later of engaging in meta-communications about their relationship. The level of anxiety and insecurity about attachment may shape the ability to generate more elaborate working models of attachments and relationships. This process is illustrated schematically in Figure. 1.
Attachments in families
The above discussion of attachments in families is obviously a simplification in that it essentially focuses on the mother–child dyad. Arguably there are multiple attachment relationships in families and this has been lucidly discussed by Byng-Hall (1995, 1997, 1999) who has documented some of the complexities and contradictions for the child when the parents demonstrate different styles. An overview of the literature on attachment theory (Steele, 2002) suggests that the primary attachment is most likely to be with the mother, although this observation itself needs to be considered further since even where the father has less to do with the child, his relationship with the mother may in turn influence the child. For example, where the father has a hostile, critical relationship with his wife this may propel her to meet some of her emotional needs through her child. However, her attention may fluctuate and be unreliable since she may be distracted and tense as a consequence of marital conflicts. Byng-Hall (1995, 1999) has here described the important reversal processes whereby a child can take on the role of being a carer for a needy/dependent parent. In fact he has been influential in pointing out that attachment is always a two-way process in that the parent is also attached to, and has attachment needs met, by the child. These vary as the child develops and grows older. Interestingly, Haley (1973) pointed to this much earlier in describing the ‘leaving home’ stage of the life cycle in terms of ‘weaning parents from their children’.
Attachment narratives
Every situation we meet with in life is constructed in terms of the representational models we have of the world about us and ourselves. Information reaching us through our sense organs is selected and interpreted in terms of these models, its significance for us and for those we care for, is evaluated in terms of them, and plans and actions conceived and executed with those models in mind. On how we interpret and evaluate each situation, moreover, turns also how we feel. (Bowlby, 1980, p. 229) Bowlby adds that the cumulative effect of our early experiences, especially of others’ responses to our requests for care and protection when threatened or distressed, becomes represented as a ‘working model’. This may also be seen as a belief system, construct system or dominant narratives (Procter, 1984; Dallos, 1996). Byng-Hall (1997, 1999) makes the important point that a child’s narrative develops within the matrix of the family dynamics and relationships. The parents may treat their children’s distress in somewhat different ways, and in turn siblings may react to each other differently. However, it is also likely that the family does also develop a dominant narrative style. This possibility is supported by other ideas, such as the ‘family paradigm’ (Reiss, 1980) and Procter’s (1981, 1984) notion of core family constructs.
In brief, the working model consists of two interdependent parts:
1 A view of the world in terms of whether people are likely to be able or willing to meet one’s needs, whether the world is a dangerous place in which no one will be willing to help, and the need to deal with feelings on one’s own.
2 A view of the self as worthy or unworthy of love and affection, for example, feeling that I am disgusting and unlovable, and should not expect love and affection because I am useless and so on. Children who have experienced insecure attachment typically have low self-esteem and sometimes intensely dislike themselves.
Coherence and reflectivity
The work of Mary Main (Main et al., 1985) suggests that not only the
content but also the form of adults’ accounts of their childhood is
shaped by their experiences. The study of attachments as internal
representations has been conducted largely through the analysis of
accounts of early family experiences of adults using the methodology
of the Adult Attachment Interview (Main et al., 1985). This is a semi-
structured interview which focuses on:
perceptions of the nature of relationships in one’s family;
memories about how feelings and anxieties were dealt with;
memories of how the parents responded/helped one to deal with
fears and anxieties;
memories of displays of physical affection;
memories of threats and punishments;
request for specific memories to illustrate the relationship with
each parent;
requests for possible explanations about why the parents acted as
they did;
questions about the person’s thoughts about the effects these
experiences may have had on them and their relationships with
others.
Transcripts of the interviews are analysed for both the content of the
accounts and their form or structure.
Coherence. A most significant aspect of people’s accounts has been found
to be the degree of coherence. Coherence has been variously described
but there is some broad agreement that it consists of: orientation – a clear setting out of the context and participants in a story; structure – events are
connected over time and in terms of causes; affect – the story contains
feelings and evaluations about the events; integration – the events, feelings
and meanings are connected together and add up (Baerger and
McAdams, 1999). In terms of the Adult Attachment Interview, coherence
has been seen in terms of the discrepancies between general evaluative
descriptions and specific illustrations offered (Holmes, 1999). For
example, some accounts start with statements that the attachment to a
parent was close and good, but in contrast, considerable effort is required
for the person to produce any examples and these may be quite
contradictory.
Reflectivity. Accounts vary in the extent to which people are able to reflect
on their experiences, for example, to remember how they felt, why they
felt like this, how else they may have felt. Importantly this also relates to
their abilities to form ideas about others’ internal states; for example, to
be able to consider what might have been going on in the mother’s or
father’s minds - feelings, intentions, needs and explanations which may
have guided their actions (Fonagy et al., 1991; West, 1997). This has
variously been termed psychological-mindedness, sociality (Kelly, 1955;
Procter, 1981, 1984) and ‘theory of mind’ (Baron-Cohen, 1997).
According to Fonagy et al.:
The development of the reflexive self is, thus, intrinsically tied to the
evolution of social understanding. It is through the appreciation of the
reasons behind the actions of his caretakers and siblings that the child
can come to acquire a representation of his own actions as motivated by
mental states, desires and wishes.
(Fonagy et al., 1991, p. 203)
Attachment theory suggests that a central task for a child is to monitor
the emotional availability of his or her parents. Over time different
strategies are developed according to whether the parent has been
found to be readily available as opposed to unavailable. The
interesting point here is that both types of insecure strategies, namely
avoidance or preoccupation, involve an excessive amount of cognitive
and emotional effort:
Because a secure strategy develops from confidence in the attachment
figure’s availability and responsiveness children employing this strategy
spend less time monitoring the whereabouts of their parents. This frees
the child to deploy attention to other matters including play, exploration
and experimentation. At a more cognitive level, the freedom to deploy attention allows the individual to step outside the attachment action loop
and to meta-monitor internal models of self and parents.
(Kobak and Cole, 1994, p. 275)
In contrast both the avoidant and preoccupied strategies constrain a
child to be excessively involved in attempting to dismiss attachment-
related experiences or alternatively to be hyper-vigilant about the
potential to gain some affection and reassurance. The avoidant
strategy may be seen to incur a similar cost despite a child appearing
to be disinterested. Dozier and Kobak (1992), for example, found that
adolescents who displayed avoidant strategies reacted with the
greatest increases in physiological measures of stress (increased skin
conductance–sweating) when taking part in the AAI interview. This
suggests that they attempt continually to avoid such topics and
emotional encounters at a high emotional cost.
Eating disorders and disruptions of attachments
A number of clinicians and researchers have argued that attachment
disruptions play a central role in the development of eating disorders
(Hilda Bruch, 1973, 1978; Palazzoli, 1974; Masterson, 1997). A
consistent observation has been that anorexia nervosa develops from
significant disturbances in the relationships between the child and the
primary carer (most typically the mother). Broadly these may be
summarized as:
The failure to develop autonomy from parenting figures, espe-
cially the mother, due to parental intrusiveness and over-control.
Rewarding of dependency of the child so that she develops a
compliant ‘false self ’–a ‘good girl’ as a defence against parental
intrusiveness.
A vulnerability and inability to express emotions, especially anger,
which tends to surface in adolescence due to the stresses and
demands of that period.
An early confusion for the child about his or her bodily signals; for
example, the need for food becomes confused with the parent’s
wishes and needs so that the child finds it hard to separate
physically or emotionally.
More broadly, Minuchin et al. (1978) have argued that though family
dynamics are invariably complex and to some extent unique, these
may be seen to show some common features in their essential dynamics, for example, that there is a tendency for relationships to be
over-involved (enmeshed) and for there to be a fear of expression of
conflict and a tendency to attempt to avoid expression of feelings.
A number of empirical studies (e.g. Humphrey, 1989; O’Kearney,
1996) appear to offer some support for the reports from clinical
studies of the development of eating disorders as being related to an
experience of attachment for the child of low emotional care and
intrusiveness. However, there is a great danger in offering a critical
and blaming model of families, and especially mothers in these
models. Not least there is the need to identify and pursue the possible
origins of the mother’s own anxieties and insecurities in clinical work
(Doane and Diamond, 1994; Byng-Hall, 1995). For example, many
mothers experience considerable anxiety at not being a ‘good
enough’ mother. This notion is arguably shaped by culturally shared
but unrealistic expectations about self-sacrifice, unflinching avail-
ability and consistent positive emotions towards their child. Such
social pressure for women to conform to certain traditional stereo-
types of thinness – concern with food, self-sacrifice, nurturing others
rather than the self, and denial of pleasure – may be seen to conspire
to shape this particular disorder as more likely for young women.
White (1983) has argued that:
Vulnerability to the symptoms of anorexia is considered the outcome of a
certain rigid system of implicit beliefs. This view is in conflict with opinion
that the symptoms . . . are a mechanism of denial and rebellion, tantamount
to personal survival or related to a battle for control. Instead, it is
considered that the symptoms of the anorexic member reflect the way in
which she is inadvertently putting her ‘self ’ to one side and unknowingly
colluding with rather than rebelling against, family tradition . . . all family
members . . . are considered victims of these oppressive beliefs.
(White, 1983, p. 259)
Insecure/dismissive narrative styles and anorexic narratives in families
The cumulative experience of insecure attachments in childhood is
represented in the types of narratives that people hold about these
experiences. Support for this comes from a number of studies. For
example, Ward et al. (2001) found that young people with anorexia
and their mothers predominantly had a ‘dismissive’ style on the Adult
Attachment Interview. They found that 79% of the daughters and
70% of the mothers showed a ‘dismissive’ style on the interview. An
earlier study by Fonagy et al. (1996) gave a figure of 64% of people with eating disorders having a preoccupied style but this does not
clarify what proportion were anorexic as opposed to bulimic.
Candelorim et al. (1998) suggest that restricting anorexics and those
with bulimia both show insecure though different attachment styles.
The suggestion that people with anorexia predominantly show a
dismissive attachment style is also supported by clinical experience of
the well-recognized problem of motivating this group to engage in
clinical discussion and exploration (Kobak and Cole, 1994; O’Kear-
ney, 1996; Fonagy et al. 1996, 1998).
Connections between the observations about the nature of
narratives characterizing insecure/avoidant attachment styles and eating disorders - namely anorexia nervosa?
Difficulty in accessing memories of early experiences
A commonly observed characteristic of families with an anorexic
member is that they appear to find it extremely difficult to engage in
conversations about their feelings and relationships. Results employ-
ing the AAI with this group suggest that memories of early attach-
ments and relationships in families are sparse. This is indicated in the
details of the analysis of the studies using the AAI mentioned above
and our own current research which uses a modified form of the AAI.
Difficulty or reluctance to engage in an expression of feelings and emotions
A widely documented observation is that many of the families appear
to be extremely wary of expressing any feelings, especially conflicts.
The work of Treasure and Ward (1997), for example, highlights the
need to take considerable time to establish a working therapeutic
relationship and inspire intrinsic motivation for these young people
to be able to start to engage in therapeutic conversations. Parents also
often appear to find it extremely difficult to describe and acknowledge
positive emotional experiences with their own parents, and more
generally appear to see such a discussion as irrelevant (although
arguably this may also be due to the level of distress in the family which
may make such discussions difficult). Moreover, there appears to be
a tendency to engage asceticism, self-denial and self-sacrifice. For
example, Palazzoli (1974) has described the mothers of anorexic girls
as displaying an attempt to conform to rigid gender roles of nurturing
others, denying pleasure and enjoyment of sexual intimacy. The
expression of feelings and conflict apparently so deeply embedded in anorexic dynamics may relate to the deeply terrifying prospect that by
admitting to these needs the person once again risks rejection, denial
and frustration. Furthermore, this experience of denial also leads to
low self-esteem which is characteristic of anorexia nervosa and the
feeling of being worthless and not deserving of pleasure, including
centrally pleasure through food. Our own clinical experience and
ongoing research (Dallos and Laville, 2003) suggests that these kinds of
reflective conversations about feelings, relationships and vulnerabilities
are difficult for this group of young people and their families.
Lack of coherence in the narratives
Typically in describing the early childhood of the anorexic member of
the family, they are described as having been happy, without
problems, well-behaved, contented and well-functioning despite
evidence of events to the contrary (Bruch, 1973; Palazzoli, 1974;
Kobak and Cole, 1994; Dallos and Laville, 2003). For example, the
impact of the loss of a grandparent or crises for one or other parent
are skated over and instances or periods of the child clearly not being
happy are minimized or excluded from the overarching view of her
as functioning well up to the start of the disorder. The counter-
evidence to the all-encompassing story of well-being often emerges in
fragmented, sporadic admissions over several sessions.
Lack of reflexive narratives
Both the person suffering with the anorexia and family members
typically display an apparent difficulty in contemplating possible
alternative narratives (Kobak and Cole, 1994; Dallos and Laville,
2003). There is typically considerable difficulty and seeming
resistance to contemplating narratives alternative to the dominant
medical and intrapsychic explanations. It seems that an ability to
reflect on one’s own thought processes, the possibility that others may
see things differently and a wider acceptance to adopt a propositional
position to one’s own beliefs is difficult. Circular questioning often
appears to be an extremely painful task for these families. Questions
about how other members may feel and think or how the interactions/
conflicts between two members may influence the feelings of a third
often elicit very brief replies, if any.
These descriptions contain a suggestion of deficit or inadequacy.
This is not the intention. In fact the behavioural attachment styles, and the content and form of narratives, may be seen to fit the
interpersonal context in which the child is immersed. For example, if
care is reliably not available (for a variety of possible reasons which
are not the ‘fault’ of the carer) then it makes sense for the child to
develop ways of avoiding disappointment and feelings of rejection.
Therapeutic approaches
Consistent with the danger of adopting a deficit model, a problem
with attachment perspectives may be that they constrain our thinking
in simplistic terms of predominant attachment styles. Although it is
possible to consider people’s childhood experiences as predominantly
tending towards a particular style it is also likely that their experiences
are more complex and unique. Non-pejorative therapeutic approa-
ches can flow from the work on attachment experiences and internal
representations. A consideration of attachment styles can help
therapists to think about the content and form of the therapeutic
conversations to which they invite families. For example, with a family
showing predominantly avoidant styles the therapeutic orientation
may be to encourage expression of feelings and thinking about
relationships whereas with ambivalent attachment styles the therapist
may attempt to generate more coherent and less contradictory
narratives. However, these are not exclusive and need not promote a
prescriptive or simplistic approach based upon rigid classifications of
families and their members in terms of attachment styles.
Similarly, Byng-Hall (1995) points out that though it is useful to
consider the nature of the primary attachments in a family, especially
between the mother and her children, each family consists of a web of
interconnected attachments. In particular a child may play a role in
regulating the nature of the attachments between his or her parents –
the near/far distance regulation (Byng-Hall, 1995). At times one or
other child and a parent may ‘emotionally capture’ each other so that
other family members are excluded. The nature of the attachments
may also shift and alter according to a variety of crisis-inducing
factors, such as inevitable life-cycle transitions, the birth of other
children, children leaving home and other events including loss,
illness, problems at work and so on.
A tentative therapeutic approach is offered which has been
developed with families where a member is displaying an eating
disorder. This attempts to take into account the attachment dynamics
described above and the internal representations of these in each member of the family in the form of a set of family narratives or
constructs (Procter, 1981, 1984; White and Epston, 1990; Dallos,
1996). This therapy consists of four stages:
1 Creating a secure base: Byng-Hall (1995) has described how the
therapy situation can evoke the family’s characteristic attachment
styles. Some families view it with trepidation and as a situation where
they feel it is imperative not to give anything away about them-
selves for fear of being blamed. Others approach it as a situation
that may save them and somewhere where all of their needs will
be met. Importantly there may be powerful differences between
family members in how much trust as opposed to distrust and fear
they feel about the situation. A core task for the therapist is to
make all of the members feel safe. For this it is important to adopt
a non-blaming position, to go at a pace which is comfortable for
the family or even to adopt a ‘conservative’ or paradoxical position
stressing that there is no need to rush into making any changes.
2 Exploring attachment narratives: Once a sense of trust is established
the therapy can move towards an exploration of the ways of
dealing with distress, fear and anxiety – how members are able to
comfort each other and what their ideas are about how this should
occur. One of the least threatening and powerful ways of achieving
this is through a transgenerational genogram. Children can listen
while parents discuss their own relationships with their parents.
This can lead to a discussion of corrective and replicative scripts –
what did they learn and resolve to do the same or differently with
their children. This helps to connote their current styles in the
family in positive terms as trying their best to make it good for
their children. Often the parents then volunteer their own views
about what is or is not working currently. Engaging in abstract
conversations about relationships and feelings may be difficult for
some families, especially those with a dismissive narrative style.
Use of visual aids, such as microsculpts, drawings, or viewing
videos may help them to strengthen their narrative and reflective
skills. In contrast for families with a preoccupied style, structured
discussions and activities, such as asking particular pairs or groups
in a family to listen without interruptions to other members, can
help them to organize their narratives.
3 Considering alternatives: The discussion of transgenerational scripts
often leads to a consideration of alternatives. This can be fostered
by the use of circular and hypothetical questions; for example, in terms of how their family might look to an outsider, what might
have been different if the parents had had a different kind of
experience, or what kinds of attachments they think the children
may have with their children in the future. The children can be
invited to comment on what they may think about doing the same
or differently with their children, when and if they have any.
Discussions about why they may not have any children themselves
can of course be very revealing of anxieties and disappointments.
4 Maintaining the therapeutic base: For many families establishing a
trusting relationship with the therapist and the team has been a
major task and change in their typical patterns. Many have also
experienced an endless procession of broken attachments with
professionals who have come into their lives, made promises to
‘look after them’ and then disappeared. It is important not to
continue this cycle which fosters despair and lack of trust. Termi-
nation of therapy therefore needs to be collaborative. In some cases
it can be phased out gradually, but with some contact by phone or
writing maintained to communicate that the team is continuing to
hold the family in mind even if they do not still need to meet.
The following is an example of the application of this approach in a
family where the predominant attachment disruption appeared to be
with the father.
Case study – The M Family1
At the time Mary, aged 19, was attending an eating disorder unit as a
day-patient following a three-month period as an inpatient. She was
living at home with her father (Bill), and older brother (Peter) who
was drinking quite heavily, which was of some concern, especially to
his mother. Mrs M (June) was living with her mother and father
nearby, having ‘moved out’ of the family home approximately six
months prior to the start of Mary’s anorexia. Mary had gone to
university some distance away from home about four months after
her mother had moved out. She quickly lost weight and had to return
home after six weeks, and was admitted to a local eating disorder unit.
After eight sessions of therapy with the family Mary left home to work
in a hotel some distance away from the family. During this time monthly sessions continued with the parents. When Mary returned
home, occasional sessions at intervals of six weeks or so continued to
offer support and to monitor progress.
The relationship between Mr and Mrs M was complex. Mrs M
came to the house every day to cook, clean and shop and performed
all the duties that she would if she had still been living with Mr M,
except that she went home to her parents’ house. Sexual intimacy had
apparently ceased but there was considerable confusion as to the
nature of the marital relationship. Although neither of them had a
new partner it was not clear whether their relationship had ended or
was current. Consistent with this Mary indicated that she felt confused
about her parents’ relationship and confided that she was very angry
with her mother, partly because she thought that her mother had
spread a false rumour that she and her father were having an
incestuous relationship.
A characteristic feature of the early sessions was that Mary seemed
very distressed and cried continuously. Although aware of her distress
neither parent made overt attempts to comfort her. When asked what
her sadness was about she repeated that ‘people are lying to me, I
don’t know what is going on’. We wondered whether this was a
comment on the ambiguous nature of her parents’ marriage. It also
seemed that she was ‘triangulated’ between her parents. On the one
hand, she appeared to have a reversed attachment in that she was
attempting to sacrifice her own needs in meeting those of her father.
For example, she had attempted to console him when his wife had left and submerged her own anger and protest at her mother ‘abandoning’
her and the family. On the other hand, her position also appeared to
elicit anger and jealousy from her mother who wanted to resume a
relationship with her husband and had possibly moved out as a protest
at his emotional distance. It later transpired that both of them had
indulged in short affairs, and Mr M confided in an individual session
that Mary was the only person whom he had ever told about his brief
affair, assigning her an important role as his confidant.
An attachment perspective suggested that perhaps Mary was
sacrificing her own needs in order to attempt to meet the attachment
needs of both her parents, and especially her father. This reversal has
been described by Byng-Hall (1995, 1997) as a profile of compulsive
care-giving. It is also characteristic of young people with anorexia, for
example, in their efforts to cook sumptuous meals for others which they
do not consume themselves. There is an underlying suggestion of ‘I am
not good enough to have my attachment needs met’ and an attempt to
deny the pain of this by compulsively looking after others. Part of our
approach was to try to help her to move out of this triangulated
attachment position so that she could be more independent of her
parents’ relationship. It seemed appropriate that she should develop a
more age-appropriate role with her parents where she could both offer
and expect some emotional care-giving without becoming consumed by
trying to take care of her parent’s attachment needs.
The therapy will be described employing the phases indicated above. Creating a secure base
The therapeutic approach starts from the premise that for families
with an anorexic member the therapy situation is likely to be
threatening, aversive and anxiety provoking. The overall orientation
initially is to offer a warm, non-blaming and validating position. This
is communicated verbally and non-verbally through a calm tone to
the session, checking if they are feeling comfortable with the situation
and pace of the discussion. More specifically an externalizing
framework was adopted to help unite the therapist and family against
the anorexia and help avoid a potential sense of being blamed (see
also Byng-Hall, 1995). It was emphasized that the purpose of the
sessions was not to apportion blame, and that looking for causes
might be futile, though we would try to find ways of resisting the
problem. Family members were also asked how they felt about an approach where we did not spend all of the time in the sessions
looking at the anorexia but also discussed other matters:
Therapist: You have probably spent quite a bit of time trying to understand how
the eating problems have come about. One of the things we find
often is that the anorexia can start to eat away [looking to Mary] at
the young person’s life until there is hardly anything left. So, if it’s
OK with you maybe we could spend some of the time talking about
the anorexia and some time talking about other things, friends, work,
education – the future, so that when eventually we do manage to help
Mary defeat the anorexia she will have a life ahead of her. In fact
anorexia is more likely to linger or try to come back into your lives if
a person is bored, lonely, frustrated or dissatisfied with the rest of
their life. How does that sound to you all?
Mary; [nodding in agreement] Yes, that sounds reasonable to me.
Mr M: Whatever you think will help.
Mrs M: Yes, she does want to do things . . . .
Therapist: I am not talking about these things changing quickly . . . anorexia is
very persistent and will keep trying to come back into Mary’s life. It’s
a little bit like a spiral you feel like you are going round in circles but
at each turn you are going forward a little bit as well. Anorexia likes
to divide families and we find that working together, offering a united
front can be helpful in keeping it at bay. It might be a tough, long
struggle . . . .
Mr M: We will do whatever you think is helpful . . . .
Exploring attachment narratives
Building on the general frame of needing to work together to resist
the anorexia, the next phase of therapy can move into an exploration
of the attachment relationships in the family, such as emotional
closeness, divisions and conflicts, how they are able to meet each
other’s needs, offer support and help each other to manage stresses
and problems. This includes exploration of how anorexia has come
into their lives and what changes it has made to these relationships.
Mary appeared to be very distressed in the early sessions and
repeatedly mentioned feelings that things were ‘unreal’ and that
people were ‘lying to her’. Eventually she confided that she was
particularly angry with her mother:
Mary: I would like to spend some time on my own with dad but it’s not
Mrs M: Mary: allowed.
I don’t stop you.
But you give me such a hard time about it. I know you are angry about it.
Therapist: [to Mr M] It appears sometimes that you are sort of caught in the
middle, both Mary and your wife and competing for your affection.
. . .
Mr M: Mrs M: [smiling] I don’t think so really . . . well perhaps. . . .
Yes, it does feel like that sometimes. I’m not sure that Mary likes us to
be together.
Following this exploration of the current attachment dynamics
there was an attempt to connect these to the parents’ attachment
histories. This was framed in terms of how their experiences might be
influencing their ideas about Mary and what they could apply to help
build a life for Mary and themselves without the anorexia. Part of this
exploration attempted to discuss Mary’s difficulties as not only just
related to the anorexia but also as part of ‘normal’ development, for
example, that becoming a young adult, moving away from home and
becoming more independent involves difficulties for all families. This
led into a discussion, with the aid of a genogram, of how each parent
left home, and more broadly into the nature of their relation-
ships with their parents. During this discussion Mrs M described that
she had moved out to start work and that her family had been close
and warm. She felt there had been few problems. However, to our
surprise Mr M had quite a different story to tell:
Therapist: So can you tell me Bill, how was it for you, becoming adult, leaving
Mr M: Therapist: Mr M: Therapist: Mr M: Therapist: Mr M: Therapist: Mrs M: home . . . ?
Well I didn’t really have a home. I was brought up in various
children’s homes, it was OK I suppose . . . .
Could you tell me a little bit more about that, where were your
parents . . . ?
My mother was very ill and in hospital, she died in hospital when I was
5. My father drank a lot and carried on with various women. His answer
to every problem was to have a drink. I thought it was terrible my mum
lying in hospital while he was doing that, but what can you do?
So what happened when your mother died?
His girlfriend moved in with us and she couldn’t stand me so I was
put in a children’s home . . . .
That must have been pretty tough for you?
No, not really, I don’t think about it, it doesn’t really matter to me.
You just have to get on with life . . . no point crying about it.
Have you ever talked to anybody before about these experiences?
He has told me, but I’m glad he is doing it now . . . he keeps it all
bottled up I think.
This revelation from Mr M suggested that he had experienced an
extremely insecure and sad childhood. His predominant way of
r 2004 The Association for Family Therapy and Systemic Practice60 Rudi Dallos
coping had been to deny his feelings – an avoidant attachment
strategy. Possibly this had eventually driven his wife away – she
remarked in a later session that ‘I love him but he won’t let me get
close to him, I don’t know what is going on with him’. Despite
attempts to deny his needs Mr M eventually admitted that he had
been hurt by his wife’s departure and possibly Mary had stepped into
the role of surrogate wife to meet her father’s emotional needs. Mr M
nevertheless denied that he needed emotional support from his
daughter but at the same time described a daily ritual of massaging
her feet to ‘help her to relax’. Although the team were initially
concerned at the potential implications of sexual abuse it was felt
more likely that this was his avoidant way of seeking some physical
and emotional contact.
At the same time Mary may have tried to deny her own feelings
of loss of her mother by taking a critical stance towards her. When she
tried to leave this situation to go to university she possibly worried
about both of her parents, especially her father. In addition, she may
in turn have had some of her own attachment needs met by this close
relationship with her father and had returned home when these
conflicting issues became unbearable.
Considering alternatives
A number of the subsequent sessions were focused on exploring the
possible impact of Mr M’s experiences and on the parents’ relation-
ship. It was suggested that they might attend as a couple to discuss
their own issues and they agreed to this. Various narratives were
explored with the couple and the family; for example, the possibility
that Mary may have been trying to keep the family together through
the anorexia. We also discussed the possibility that perhaps she was
also being loyal in following her father’s footsteps in that she had been
in institutions. Perhaps she was also close and loyal to her mother in
trying to look after everybody emotionally. Her mother was perhaps
likewise sacrificing herself in that even though she had left she was
still caring for the family. Likewise, Mr M was described by his wife
as ‘working all the time’ and was sacrificing himself to look after
everybody. In short, it was considered that perhaps none of them felt
they deserved to have their needs met:
Therapist: What developments have occurred since the last session?
r 2004 The Association for Family Therapy and Systemic PracticeMary: Mrs M: Attachment narrative therapy: eating disorders 61
The way people guessed at what I was thinking wasn’t helpful . . .
reasons why I won’t get better you said to keep the family together.
. . . I don’t think that’s right . . .
Mary said in the past she feels more secure with us apart. I don’t
think that’s on the right lines about how I feel.
Mrs M developed this theme to indicate that she did want to be
back with her husband but that this was hard because he was so
emotionally shut off. Eventually in an individual session and later in a
session with the couple, Bill admitted that he still cared for his wife
and wanted her back. It seemed that his reluctance to admit this was
because he did not want to betray his special relationship with Mary.
When Mary went away to work in the hotel her parents agreed that
Mrs M would move back and that he would phone Mary to tell her.
Meanwhile Mrs M and Mary had been encouraged to re-establish
their attachment and closeness and had been going out together. Mrs
M had also insisted on taking Mary to the hotel where she worked.
Some of these changes in the attachment patterns were explored:
Therapist: [to Mr M] How does it feel that Mary is perhaps getting closer to her
Mr M: Therapist: Mr M: mother?
I just stay out of the way, it’s OK for me. . . .
How do you think Mary feels about this?
She doesn’t seem too bothered, she’s going her own way now but we
do talk sometimes.
An attempt was made to monitor the changes in Mary’s attachment
to her parents carefully and not to go too fast. Gradually Mary was
spending more time with her friends, had started to work again and,
though still struggling with the anorexia, she was managing to avoid
readmission to the unit.
Maintaining the therapeutic base
Some significant changes appeared to have occurred in the family,
especially that Mary seemed to be less triangulated between her
parents and was becoming emotionally more independent and more
connected to her mother. However, there was a danger that her father
was cutting off too quickly emotionally and this was upsetting for her.
His history in childhood had been that his needs would not be met
and there was a danger that he was feeling this again. Sessions at
intervals of about six weeks were offered. The family stated initially
that they did not need these sessions and that the situation had greatly
r 2004 The Association for Family Therapy and Systemic Practice62 Rudi Dallos
improved. Mrs M was particularly delighted at the changes, while Mr M
was more reserved but agreed. Mary still showed some doubts but
agreed that therapy could stop. After a break of about four months
the family took up the offer to have a review. The positive changes
were continuing but some issues, such as Mr M working too hard,
were raised. The pace of Mary’s independence was discussed and the
family said that they now did things together and that Mary did not
feel ‘pushed out’ emotionally.
Discussion
An attempt has been made to outline some developments in
attachment theory, particularly the exciting developments in work
exploring attachment narratives. It has been suggested that this offers
a way of linking systemic and attachment models in outlining how
early experiences lead family members to have different kinds of
narrative systems. In relation to anorexia it has been suggested that
the characteristic patterns of early interactions resemble the patterns
found in insecure and predominantly avoidant attachment styles.
This goes some way to explain the common clinical experience that
these families find it difficult to discuss feelings, relationships and
conflicts. More specifically, one or both of the parents appear in many
cases, such as in the case study provided, themselves to have
experienced insecure attachments. This both leads them to engage
with their children in certain ways and later makes it difficult for them
to be able to discuss or reflect on this.
Some implications for therapy have been discussed, but one of
particular importance is that despite acknowledging the parents’ role
in the development of the disorder, it can help the therapist to take a
compassionate view. For example, Bill appeared to have unresolved
attachment difficulties from his childhood, which left him feeling
insecure but also made it hard for him to be able to think about his
own history. This can imply a pessimistic ‘cascade of pathology’ down
the generations’ view but this need not be the case. The evidence
from attachment theory is that despite painful, insecure attachment
histories it is possible to transcend these if people are able to develop
coherent narratives about their experiences. It is suggested that a
therapeutic approach here can effectively combine narrative and
attachment approaches by helping families to start to explore, from a
secure therapeutic base, their experiences, to gain the ability to reflect
on them and move towards ‘externalizing the past’. This involves
r 2004 The Association for Family Therapy and Systemic PracticeAttachment narrative therapy: eating disorders 63
discussing with them how they need no longer be prisoners of their
past experiences and can move on to relate to each other emotionally
in some different ways to the traditions in their families.
Finally, it is suggested that further clinical and research exploration
of the attachment histories of parents in such families may be
rewarding. For example, it would be interesting to explore how the
attachment narratives have shaped decisions about how the parents
deal with their children’s attachment needs and their own. In some
families children are despatched to residential schools without much
evident consideration for their attachment needs. It is also of consi-
derable clinical interest to compare these families with others where
the parents have experienced similar attachment disruptions but have
been able to compensate, for example, through supportive friendships,
and have found ways of developing coherent narratives. It is important
to consider the related possibility that people develop multiple rather
than single attachment narratives and how these interact.
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