Attachment, Trauma, and Eating Disorder Mark Schwartz, Sc. D., Castlewood Treatment Center for Eating Disorders The attachment system of the brain is conceived as a biologically and evolutionary-based survival system that evolved to encourage people to connect with other people in times of distress to improve their safety. The rules governing that system are laid down in early childhood through close attunement between the infant and caregiver, and are actively implemented thereafter. Sometimes attachment goes awry or is incomplete, resulting in too much or too little attachment. The avoidant child actively “snubs or ignores” the mother, restricting his attention while exploring his environment in a hyperactive fashion in order to discourage attachment (Wallin, 2000). The preoccupied child seems content but strictly confines his attention to monitoring his mother’s whereabouts, ignoring exploration and mastery. Attachment theory suggests that restrictive anorexia or binge eating could be a dismissive strategy to actively keep the individual from needing food and love, or to substitute the transitional object value of food preoccupation for needing people. A failed attachment system exposes the infant to extreme levels of unmodulated stress, aloneness, and inner emptiness. This stress can drive the urge to restrict, overeat, or both. Addictions, in general, provide an illusion of control when individuals experience the disequilibrium resulting from the simultaneous activation of their attachment system and fear system. When the person who cares for you is also perceived as dangerous, the result is this type of destabilizing dysphoria. At first glance, eating disorders appear to be about preoccupation with food. On closer observation though, the obsessive regulation of the intake of food is often a frantic attempt to cope with life stressors, particularly intense, dysregulated emotions and confusion regarding identity and self-esteem. Eating obsessions may be used to avoid potential rejection from friends and romantic partners. They can also create the unfortunate, self-fulfilling outcomes that reinforce the original unrecognized, yet enacted, fears around attachment. Unable to establish a stable identity base, 1 the individual states, “I don’t know who I am,” “I feel like an imposter,” or “I’m really bad, but pretend to be good.” This confusion and dichotomy is exemplified in the oft-repeated history of the “good girl who earns “A’s” and never gives anyone a “moment of trouble,” who then compulsively lies, steals, and has promiscuous sexual relations. At the core of any individual’s capacity to bond, lie self-empathy and the related capacity for self-care. Without a caretaker who mirrors and validates the individual’s real self, facilitates the expression of attuned affect and who also provides meaning in situations that overwhelm, the individual is often left with feelings of profound shame. They may also display a need to people please, and experience perfectionism that is channeled into the symptom of “feeling fat.” They come to believe that only food, or the restriction of food, will reliably quell the internal emptiness. Disorganized Attachment Of increased recent interest are individuals with disorganized attachment styles (Main and Hesse, 1992-1998). Researchers originally identified children who, in “strange-situation” at 18 months of age, both approached and avoided the returning parent, often appearing dazed, confused, and apprehensive. It is as though an oddity in the structure of the attachment relationship prevents the child from consolidating a coherent strategy for bonding. This occurs in directly abusive families, or when the child’s grandparents were abusive to the parents causing them to be disorganized in their own attachment. Mary Main and Eric Hesse have developed the Adult Attachment Interview (AAI), a tool for measuring attachment in adulthood. It correlates highly with the “strange-situation” measurement at 18 months of age. The AAI has documented high levels of dismissive (avoidant) attachment among our eating disordered clients and disorganized (What are disorganized clients-can you clarify here?) clients, particularly those whose parents are enmeshed, controlling, or abusive. We are therefore attempting to devise interventions for our eating disordered clients that can change attachment styles from dismissive 2 to secure, under the hypothesis that such changes will ultimately decrease relapse or symptom substitution in long-term follow-up. Intra-Relational Interventions Common sense dictates that an individual be capable of establishing an “I” before he or she can successfully create a “we.” Since the eating disordered client lacks a cohesive sense of self, a unified clarity regarding self is a primary goal in rehabilitation. The self system is often fragmented, so a secondary goal is healing and integrating dissociated or disowned parts of self. This process proceeds from a careful understanding of and respect for the original survival function of protective parts of self, such as the parts that engage in the eating disorder or seemingly self-undermining behaviors, to a process for ascertaining the ongoing function of these behaviors. For example, anorexic parts of self may have various cross-purposes (Table II). The client can hate their eating disorder, yet fear giving it up, resulting in an internal “civil war.” She may expend immense energy in hating herself for it. Resolving these internal conflicts is essential for integration and healing. Different parts of self may also have different attachment schemas. The distinctions are clearly perceptible, particularly in the disorganized patterns. Anorexic parts can be avoidant while bulimic parts can be preoccupied with, and desperately “need,” others’ affection. Creating internal secure attachment between parts of self is requisite, or must at least be significantly underway, before secure attachment with others can be sustained. Conventional cultural thought tells us the past is unchangeable and therefore best left alone. This belief, though prevalent, does not necessarily reflect the most likely path to the type of consolidation and mastery of experience that permits mature evaluation and the freedom to move on with life. Attachment theory and research indicate that, regardless of where a client begins, her ability to acknowledge, understand, and make informed attributions around her experience, her past, and 3 particularly her key attachment relationships, is necessary before moving toward the goal of “earned secure attachment.” Creating Secure Attachment According to Mary Main, the primary characteristics of “earned secure attachment” in the Adult Attachment Interview are metacognitional thinking, and integrative thinking. These characteristics are founded on several distinct skills. These include the ability to reflect on one’s mental states, the capacity to elaborate a theory of the other’s mind, decentralizing, and the establishment of a sense of mastery and personal efficacy. These metacognitional abilities are the basis for psychotherapy. Secure attachment allows the individual to feel safe deconstructing childhood events, cognitions, and affective responses and reconsidering conclusions, then and now. The AAI’s effectiveness is based on Main’s realization that it is not only the content, but also the structure of adult accounts of childhood experiences, that provide critical data for determining earned secure attachments. The state of mind reflecting secure attachment includes: Coherence – being truthful and succinct; having relevant narratives with a steady flow of ideas, intent, thoughts and feelings that are clear, truthful, consistent, plausible and complete. Coherence comprises (1) orientation – a clear setting out of the context and participants in a story, (2) structure – events that are connected over time and in terms of causes, (3) affect – the story contains feelings and evaluations about the events, and (4) integration – the events, feelings, and meaning are connected together. In contrast, anorexic clients typically begin by describing the family as happy, problem-free, well-behaved and content, despite evidence to the contrary. Collaboration – the speaker appears to value attachment relationships and experiences. Consistency – the description of relationships with parents are supported with specific memories without the burden of prescribed family loyalties. 4 The rules of attachment are conscious and flow out of an understanding of past relationships. They are restructured to include empathy and compassion for self and others. They influence feelings and behavior and redirect attention, memory, and cognition. The individual forms ideas about others’ internal state; for example, he or she is able to consider what might have been going on in the mother‘s or father’s minds. For example, she can consider the feelings, intentions and explanations that might have guided their actions (Fonagy, et al., 1991). The individual becomes aware of different and divergent internal states. They can reflect on these origins and their divergent defenses, schemas, and emotions. This person will witness their own experience with compassion rather than shame, thereby repairing the internal disconnections and experiences of aloneness. The result is a commitment to selfcare and self-protection while maintaining healthy boundaries with others. The spiritual function of life becomes growth, play, and self-responsibility, along with self-forgiveness for maladaptive behavior and injury to self and others. Reflectivity – People can reflect on their experiences and form ideas about others’ internal states – the feelings, intentions, needs, and explanations that guided actions (Fonagy, et al., 1991). Eating disorder clients have difficulty with this and are commonly resistant to contemporary alternative narratives about how family members may feel or think and how they became unhappy. Several different attachment disruptions are common in our client’s with anorexia nervosa. (Dallas, 2001) They include: Failure to develop autonomy from parents, especially the mother, due to parental intrusiveness and over-control. Rewarding the dependency of the child so that she develops a compliant false self – “a good girl” – as a defense against parental intrusiveness. A vulnerability and inability to express emotions, especially anger, which tends to surface in adolescence due to demands of that period. 5 Un-mourned losses and issues in which everyone has ostensibly “moved on” and made the “best of it” through compulsive working or taking care of others. Parental control constantly redefining the children’s feelings and emotions to stay congruent with the family’s values. Perfectionistic home in which questioning of parental authority or diverging from parental values is negatively reinforced. Near obsessive attention is paid to social appearance and to the protection of the outside image of the “perfect family.” Clinical Applications Peter Fonagy has been the most creative researcher in delineated therapies to encourage secure attachment (see Allen and Fonagy, 2002; Fonagy et al., 2002). They have utilized Main’s insight into metacognitional thinking to teach clients, spouses, and families to increase mentalization. Their premise is that childhood attachment trauma impairs understanding of how others think or feel, and impairs the development of affect representing self-structure. Therapists focus on how the client experiences themselves and others at any give moment (Bateman and Fonagy, 1999). They identify and explore positive mentalizing, affect elaboration, improved reflection about dialogue, and means for establishing a coherent narrative that gives credibility to the client’s struggle. Psychoeducational encouragement for collaboration and a reciprocal relationship (Brolberg, 2001), attention to interpersonal cues, mastery and meaningful attachments, improves awareness of others’ mental states. We are currently adapting Fonagy’s and his colleague’s methods for eating disordered clients and using a structured hour-long weekly group therapy format to facilitate “earned secure attachment” as measured by the AAI. Conclusions In our limited follow-up, clients who establish “earned secure attachment” have a much improved prognosis in inpatient treatment. We believe the focus needs to be on food and attachmentrelated behavior simultaneously for optimal progress. 6 TABLE I TARGET SYMPTOMS FOR “EARNED SECURE” ATTACHMENT 1. Turning towards other people for self-soothing and intimacy. 2. Establishing a coherent narrative regarding one’s life. 3. Establishing metacognitional thinking in relation to family of origin. 4. Minimize idealization and family loyalties. 5. Establishing clarity with regards to self and self in relation to significant others 6. Resolution of significant losses in one’s life. TABLE II FUNCTIONS OF EATING DISORDER SYMPTOMS Substitute for life itself, safeguards against anxiety. Modulates anxiety, needs states, self esteem. Sympathetic problem to mask the truth. Maintaining her false self, object self, making her real needs with relationships with real people. Express her needs (power autonomy, comfort, soothing, recognition connection). - Recognize control of disavow needs - Medium for relational needs - Internal object Is a form of self-hate and an expression of rage. Body as a container of intolerable memory and affect. Triangle of needy child, internal saboteur, and the failed protector, keep alive the family conflict internally. 7 Bibliography 1. Allen, J. & Fonagy, P. (2002). The Development of Mentalizing and its Role in Psychopathology and Psychotherapy. Meninger Clinic, Topeka, KS. 2. Bateman, A. & Fonagy, P. (1999). The Effectiveness of Partial Hospitalization in the Treatment of Borderline Personality Disorder. The American Journal of Psychiatry, 156, 1563-69. 3. Broberg, A.G., (2001). Eating disorders, attachment, and interpersonal difficulties. European Eating Disorder Review, 9, 381-396. 4. Dallas, R. (2001). Attachment Narrative Therapy. Family Psychotherapy, 12, 43-73. 5. Fonagy, P. (1991). Thinking about thinking: Some clinical and theoretical considerations in the treatment of a borderline patient. International Journal of Psychoanalysis, 72, 639-656. 6. Fonagy, P., Steele, H., & Steele, M. (1991). Maternal representations of attachment during pregnancy predict the organization of infant-mother attachment at one year of age. Child Development, 62, 891-905. 7. Main, M. & Hesse, E. (1992-1998). Frightening, frightened, disassociated, deferential, sexualized, and disorganized parental behavior: A coding system for frightening parentinfant interactions. University of California at Berkely. 8. Wallin, D. (2000). Attachment in Psychotherapy. New York: Guilford Press. 8