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Psychiatry
Clinical Child Psychology and
DOI: 10.1177/13591045030084009
2003; 8; 521Clinical Child Psychology and Psychiatry
Rudi Dallos
Disorders
Using Narrative and Attachment Theory in Systemic Family Therapy with Eating
http://ccp.sagepub.com/cgi/content/abstract/8/4/521
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Using Narrative and Attachment Theory in
Systemic Family Therapy with Eating Disorders
RUDI DALLOS
University of Plymouth, UK
A B S T R AC T
This article proposes that recent developments in attachment theory, especially the
move towards the study of representations, offer 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 corresponding 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 trans-generational experiences of insecure/dismissive attachments.
Some implications for systemic therapy with families are outlined and an illustrative
case study is offered.
K E Y WO R D S
attachment, eating disorders, family therapy, narratives
The voice goes on in my head. I call it the anorexic minx. Iťs like a little person
that gets inside my mind and takes control of my thoughts. The voice tricks me
into believing that I am in control but I am not, iťs in control of me. Dictating
what I can and can't eat and how much exercise I should do. It never lets me
rest. Being anorexic takes up all my time, it becomes a way of life. . . .
Everything is controlled . . . Life is filled with thoughts of this illness. Anorexia
has become my way of life. It is what I know. (Lucy, 1999)
Clinical Child Psychology and Psychiatry 1359­1045 (200310)8:4 Copyright  2003
SAGE Publications (London, Thousand Oaks and New Delhi) Vol. 8(4): 521­535; 035802
www.sagepublications.com
521
RU D I DA L L O S is the Researcher Director on the D.Clin.Psychol course at the University of
Plymouth and a consultant clinical psychologist specializing in work with adolescents. He has
written several books including: An Introduction to Family Therapy, Interacting Stories and
Couples, Sex and Power.
C O N TAC T : Rudi Dallos, Research Director and Consultant Clinical Psychologist, Clinical
Teaching Unit, 4/5 Rowe St, Drake Circus, Plymouth PL4 8AA, UK. [E-mail:
rdallos@plymouth.ac.uk].
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T H I S A RT I C L E C O N S I D E R S 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. More broadly, it offers an invitation
to readers to think about how recent ideas from attachment theory can add to our
understanding and use of narrative therapeutic approaches with families.
Narrative approaches
Drawing extensively from social constructionist theory, narrative approaches emphasize,
for example, how problems in families can be seen to arise from `problem saturateď
conversation (Anderson, Goolishian, & Windermand, 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.
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 account above) 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 saturateď conversations (Anderson et al., 1986). As a difficulty
comes 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 can recognize exceptions and competencies (Dallos & Hamilton-Brown,
2000; Eron & Lund, 1993).
A central ingredient of narrative therapies is to help people to resist this process by
`externalizing' problems and seeing them as destructive visitors, rather than as an indication
of an inherent weakness. Individuals and family members are invited to consider
ways that they can gather strength together to resist the problems. 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.
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 some time, I experienced difficulties in enabling families to engage in
conversations about their difficulties, their feelings, the impact of the problems on their
relationships (and vice versa), where anorexia was the presenting problem. An exploration
of the literature on eating disorders, revealed that many practitioners also
reported these experiences. This suggested that possibly there was something about the
willingness or the ability in such families to engage in therapeutic conversations.
Although wishing to avoid the temptation to typologize families the following questions
have been raised for me:
* Is it possible that there is some commonality in families with anorexia?
* Is it possible that part of this commonality is that they are more unwilling or anxious
about engaging in such conversations than other families?
* Is it possible that they have some cognitive difficulty, which makes it harder for them
to engage in such conversations?
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Apart from these specific questions there is a broader, more fundamental question
about how narratives develop in individuals and families. Even more broadly, there are
some uneasy questions about the lack of developmental models in systemic theories.
Family life-cycle models may be offered as an exception, but arguably they only offer a
general and speculative account of the formation of each family member's internal
worlds and narrative faculties. In contrast, recent developments in attachment theory
focus on the development of narratives and people's ability to engage in reflexivity
(Fonagy, Steele, Steele, Moran, & Higgitt, 1991; Main, Kaplan, & Cassidy, 1985). Attachment
theory, despite its apparent emphasis on biologically based propositions, has come
to offer some useful ideas about narrative processes.
Attachment theory and narratives
Attachment theory, like early systemic theory, employs a biological metaphor which views
families as similar to self-corrective, homeostatic biological processes. Likewise, Bowlby
(1969) described the attachment; for example, between a mother and a child as acting to
maintain a comfortable level of proximity, safety and affection. Attachment theory is
supported by a wealth of empirical studies and observations for example, Ainsworth
(Ainsworth, 1989; Ainsworth, Blehar, Waters, & Wall, 1978) illustrated through the
`Strange Situation' (an observational/experimental study in which the mother and child
are temporarily separated) that, on reunion, infants exhibit one of four main patterns of
attachment styles: secure, avoidant, ambivalent and disorganized. Further to this, 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.
Bowlby (1969) emphasized that the accumulation of early experiences become internally
represented for the infant as a system of enduring, emotionally toned beliefs and
expectations about relationships ­ the chilďs `attachment modeľ. The evidence from the
`Strange Situation' studies suggests that the infants appeared to have learned a set of
expectations or a `working modeľ regarding their mother's responses. For example,
infants who consistently experience the parent as available, appear to develop a
representation of the carer as available when needed and of an ability to deal with threat
and distress. However, if the child repeatedly experiences the parent as unavailable or
insensitive then the child appears to remain in a state of arousal and anxiety. This is seen
again to lead to corresponding internal representations and, along with them, different
coping strategies.
Attachment theory suggests that a central task for a child is to monitor the emotional
availability of their parents. As this information is processed, 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 insecure attachment strategies
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 & Cole, 1994, p. 275)
In contrast, both the avoidant and ambivalent strategies constrain a child to be excessively
involved in attempting to dismiss attachment-related experiences or, alternatively,
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to be hypervigilant about the potential to gain some affection and reassurance. The
avoidant strategy can 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
dismissive strategies reacted with the greatest increases in physiological measures of
stress (increased skin conductance ­ sweating) when taking part in the Adult Attachment
Interview (AAI). This suggests that they continually attempt to avoid such topics
and emotional encounters at a high emotional cost.
This process is illustrated schematically in Figure 1.
Similarly, Byng-Hall (1995) points out that, although 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 losses, illness, problems at work and so on.
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, are evaluated in terms of them, and
plans and actions conceived and executed with those models in mind. How we
interpret and evaluate each situation, moreover, turns also how we feel. (Bowlby,
1980, p. 229)
For Bowlby the cumulative effect of our early experiences, especially of others'
responses to our requests for care and protection when threatened or distressed,
CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 8(4)
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CHILD PARENT
Experiences distress/ *Unavailable
threat/chaos or
**Unpredictable
Available/rejecting
Strategies:
*Avoid/distract
**Scrutinise/Reject
Figure 1. Attachment process shaping insecure attachment strategies.
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becomes represented as a `working modeľ. This can also be seen as a belief system,
construct system or as dominant narratives (Dallos, 1996; Procter, 1984), reflecting a
view of the world in terms of whether people are likely to be able or willing to meet one's
needs, and a view of the self as worthy or unworthy of love and affection.
Research using the AAI fits with the earlier behavioural observations in that the
accounts adults give of their childhood experiences can be similarly classified into corresponding
styles: secure, insecure/dismissive, insecure/preoccupied, and unresolved.
There is a considerable body of research which shows that there is a high level of agreement
between childhood attachment experiences and classifications in terms of behaviours,
for example, in the Strange Situation and the narrative styles that adults hold
(Cassidy & Shaver, 1999; Main et al., 1985). For example, children who appear to have
had experiences of avoidant attachment experiences later develop narrative styles which
are dismissive. The experience of consistently not having our attachment needs met
appears to predictably lead to a narrative style in which the importance of attachment
needs, feelings, hurts and vulnerabilities are dismissed and people seem to find it hard
to recall or to reflect on their experiences and the reasons for their parents' actions
(Dallos & Laville, 2003; Ward, Ramsay, Turnbull, Steele, & Treasure, 2001).
Importantly, the work of Mary Main (Main et al., 1985) suggests that not only the
content, but also the form of adulťs accounts of their childhood experiences is shaped by
their attachment experiences. The study of attachments as internal representations has
largely been conducted through the analysis of accounts of early family experiences in
the AAI which is a semi-structured interview, consisting of questions about memories
and perceptions of the nature of relationships in one's family, including memories of how
one's parents responded/ helped one deal with fears and anxieties. The interviewee is
asked to provide specific memories to illustrate the relationship with each parent,
possible explanations about why the parents acted as they did, and asked for their
thoughts about the effects that 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 the form of accounts has been found to be the
degree of coherence, especially discrepancies between general descriptions and specific
illustrations offered (Holmes, 1999). For example, some accounts start with statements
that the attachment with a parent was close and good but, in contrast, considerable effort
is required for the person to produce any examples and, when offered, these may appear
to be quite contradictory:
. . . a parent described her mother as `wonderfuľ, but then said that when she had
broken her arm she could not tell her because her mother would be angry . . . the
narrative is incoherent because it denies the unpleasant implications about the care
given. (Byng-Hall, 1995, p. 49)
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 might have felt. Importantly, this also relates to their abilities to form ideas about
other's internal states; for example, to be able to consider what might have been going
on in their mother's or father's minds ­ their 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 minď (Baron-Cohen, 1997):
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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 caretakers and siblings that the child can come to acquire a representation
of their own actions as motivated by mental states, desires and wishes.
(Fonagy et al., 1991, p. 203)
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 serious eating disorders (Bruch, 1973; Masterson,
1997; Palazzoli, 1974). 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 can be summarized as:
* the failure to develop autonomy from parenting figures, especially the mother,
because of parental intrusiveness and over-control;
* rewarding of dependency of the child so she develops a compliant `false self' ­ a `good
girľ as a defence against parental intrusiveness;
* a vulnerability and inability to express emotions, especially anger, which tend to
become apparent in adolescence due to the stresses and demands of that period;
* an early confusion for the child about his or her bodily signals, e.g. need for food
becomes confused with the parenťs wishes and needs so that the child finds it hard to
separate physically or emotionally.
More broadly, Minuchin, Rosman, and Baker (1978) have argued that although family
dynamics are invariably complex and to some extent unique, some common features are
observable. For example, it is suggested that there is a tendency towards a fear of expression
of conflict and a tendency to attempt to avoid expression of feelings. A range of
empirical studies (Chatoor, Egan, Getson, Mienville, & O'Donnel, 1987; Humphrey,
1989; O'Kearney, 1996) appears to offer some support for the clinical reports that see
the development of eating disorders as being related to an experience of attachment for
the child of intrusiveness and low emotional care. However, there is a great danger in
offering a blaming and critical model of families, and especially mothers. Not least, there
is the need to identify and pursue the possible origins of the mother's own anxieties and
insecurities in clinical work (Byng-Hall, 1995; Doane & Diamond, 1994). For example,
many mothers experience considerable anxiety at not being a `good enough' mother.
This notion may be shaped by culturally shared, but unrealistic, expectations about selfsacrifice,
unflinching availability and consistent positive emotions towards their child.
Such social pressure for women to conform to certain traditional stereotypes of thinness,
concern with food and self-sacrifice (nurturing others rather than the self and denial of
pleasure) can be seen to conspire to make this particular disorder 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)
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Narrative styles and anorexic narratives in families
Typologies of attachment styles can become restrictive and simplistic unless we see them
less as a `truth' and more as a framework for thinking about the possible interpersonal
dynamics that may have shaped the style and content of families' narratives and, most
importantly, how these experiences may make it hard for families to engage in the
process of therapeutic talk. Research by Ward et al. (2001) shows that there is a transgenerational
pattern of insecure/dismissive attachment narrative styles in families with
a young person suffering with anorexia (80% of the young women, and 70% of their
mothers were rated as insecure/dismissive in their narrative styles). This confirms my
own current research and clinical experience.
The cumulative experience of insecure attachments in childhood is represented in the
types of narratives that people hold about these experiences. The most striking connections
in the context of work with anorexia appear to be:
* Difficulty in accessing memories of early experiences ­ Results employing the AAI
with this group suggest that memories of early attachments and relationships in
families are hard to access and sparse in detail. This suggestion is based upon my own
clinical experience and ongoing research with interviews of young people with
anorexia and their parents. This suggestion is also supported by a number of related
studies, as well as the recognized clinical problem of motivating this group to engage
in therapy (Candelori & Ciocca, 1998; Fonagy et al., 1996; Kobak & Cole, 1994;
O'Kearney, 1996; Treasure & Ward, 1997).
* 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. Arguably, the level of distress may make
this difficult but the 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.
* Denial of needs and pleasures ­ There seems to be a tendency for family members to
engage in self-denial and self-sacrifice. For example, Palazzoli (1974) has described the
mothers as displaying an attempt to conform to rigid gender roles of nurturing others
and denying pleasure and enjoyment of sexual intimacy. The repression of feelings and
conflict, apparently so deeply embedded in anorexic dynamics, may relate to the deeply
terrifying prospect that by admitting to intimacy 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 and the feeling of being worthless
and not deserving of pleasure including, centrally, pleasure through food.
* Lack of coherence in the narratives ­ Typically, the early childhood of the member of
family with anorexia is described as having been happy and with no problems; they
were well behaved, contented and well-functioning despite evidence of events to the
contrary (Bruch, 1973; Kobak & Cole, 1994; Palazzoli, 1974). 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 over-arching view of them 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 anorexia and family
members typically display an apparent difficulty in contemplating possible alternative
narratives (Kobak & Cole, 1994). There is considerable difficulty and seeming resistance
to contemplating narratives that are alternative to the dominant medical and
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intrapsychic explanations. It seems that there may be difficulty in an ability to reflect
on one's own thought processes, to consider the possibility that others may see things
differently and the ability to adopt a propositional position to one's own beliefs. This
may go some way towards explaining the apparent difficulty that such young people
and their families appear to have for example, with circular, hypothetical or empathetic
questioning. 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, but this is not wholly
the intention. In fact, the behavioural attachment styles, and the content and form of
narratives can be seen to `fiť 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 `faulť of the carer) then it makes sense for the child to develop ways of avoiding
disappointment and feelings of rejection.
Attachment narrative therapy
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. However, a consideration of attachment styles can help therapists to think
about the content and form of the therapeutic conversations that they invite families
into. For example, with a family showing predominantly dismissive styles the therapeutic
orientation may be to encourage expression of feelings and thinking about relationships;
whereas, with ambivalent attachment styles, towards attempts to generate more
coherent and less contradictory narratives. However, these attachment styles 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.
A tentative therapeutic approach is offered which has been developed with families
in which a member is displaying eating disorders. This attempts to take into account
attachment dynamics and the internal representations of these in each member of the
family in the form of a set of family narratives or constructs (Dallos, 1996; Procter, 1981,
1984; White & Epston, 1990). This therapy consists of four stages:
* creating a secure base;
* exploring attachment narratives;
* considering alternatives;
* maintaining the therapeutic base.
The following is an example of the application of this approach in a family in which
the predominant attachment disruption appeared to be with the father (Figure 2).
At the time Mary, aged 19 was attending an eating disorder unit, as a day-patient, for treatment
of anorexia following a three-month period as an in-patient. She was living at home
with her father and her older brother who was drinking quite heavily, which caused some
concern ­ especially to his mother. Mrs M was living with her parents nearby having
`moved ouť approximately six months before the start of Mary's anorexia. Mary had gone
to university some distance away from the family home about four months after her
mother left. 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
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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 as if she had still been living with Mr M. 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 might have had an incestuous relationship.
A characteristic feature of the early sessions was that Mary seemed very distressed and
cried continuously. 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 parenťs
marriage. It also seemed that she was `triangulateď ­ caught in the middle. She was closely
attached to her father, perhaps meeting his emotional needs and having consoled him
when his wife separated from him. However, her position also appeared to elicit anger and
jealousy from her mother who wanted to resume a relationship with her husband and had
moved out as a protest at his emotional distance. It transpired that both of them had
indulged in short affairs and Mr M confided in an individual session that Mary was the
only person that he had ever told about his brief affair, assigning her an important role as
his confidant.
An attachment perspective suggested that perhaps Mary was attempting to meet the
emotional needs of both her parents, and especially her father. Part of our approach was
to try to help her to move out of this triangulated position so that she could be more independent
of her parenťs relationship. Also, it seemed appropriate that the she could
develop a more age-appropriate role with her parents in which she could both offer and
expect some emotional care-giving without becoming consumed by trying to take care of
her parenťs attachment needs.
The narrative style of each of the family members was that Mary spoke very little and
seemed angry and frequently fearful; Mr M minimized the possible emotional impact of
DALLOS: ATTACHMENT THEORY, NARRATIVES AND SYSTEMIC THERAPY
529
Mrs M Mr. M
Mary (19) Peter (22)
Children's
homes
Figure 2. Case study ­ The M family.
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his childhood and generally presented as if there was not much to be concerned about;
Mrs M seemed more positive about the value of discussing feelings and relationships but
appeared to find it hard to formulate ideas about the possible connections between Mary's
difficulties and their relationships with each other. There was a powerful process of Mary
repeatedly showing extreme distress at points at which difficult feelings were raised (for
example, regarding conflicts between the parents). Mr M would typically smile as if to say
`it is no big deal, I don't get emotionaľ and Mrs M would also halt the expression of
feelings by `giving up' and showing an `iťs hopeless' exasperation. Overall, there was a
sense of shared `rules' flowing from their dismissive narrative attachment style of `iťs best
to avoid difficult feelings and iťs dangerous to express our needs and vulnerabilities'.
However, in contrast to many families in our experience with such problems, they shared
a commitment to attending for therapy and did not appear to view us with a high level of
distrust.
The therapy is described employing the phases indicated above.
Creating a secure base
In the first phase of the therapy a non-blaming framework was offered including an
externalizing framework as to how we could all work together to resist the anorexia (see
also Byng-Hall, 1995). It was made clear that the purpose of the sessions was not to look
for blame and that we might never fully discover the causes. However, we would try to
find ways of resisting the problem. The family were also asked how they felt about an
approach in which we did not spend all of the time in the sessions looking at the anorexia
but also spent time on 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 at the young person's life until there is hardly anything
left. So, if iťs OK with you maybe we could spend some of the time talking
about the anorexia and some 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: 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. Iťs 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. . . .
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 different aspects of the 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
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and repeatedly mentioned feelings that things were `unreaľ 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 iťs not allowed.
Mrs M: I don't stop you . . .
Mary: 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 middle, both
Mary and your wife competing for your affection, . . .
Mr M: (smiling) I don't think so really . . . well perhaps
Mrs M: Yes, it does feel like that sometimes . . . I'm not sure that Mary likes us to be
together.
Following this exploration of the current family dynamics there was an attempt to
connect these to the parenťs 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 just related to the anorexia but as part of
`normaľ 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 relationships 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. There had been few problems she felt. This sort of blandly positive account with
lack of detail, or any memories of conflicts, is characteristic of dismissive narrative attachment
styles. 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 home . . .?
Mr M: Well I didn't really have a home. I was brought up in various children's homes,
it was OK I suppose.
Therapist: Could you tell me a little bit more about that, where were your parents . . .?
Mr M: 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?
Therapist: So what happened when your mother died?
Mr M: His girlfriend moved in with us and she couldn't stand me so I was put in a
children's home . . .
Therapist: That must have been pretty tough for you?
Mr M: 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.
Therapist: Have you ever talked to anybody before about these experiences?
Mrs M: 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 coping had been to deny his feelings which
Mrs M complained had driven her 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 and distress, Mr M eventually admitted that he had been hurt
by his wife's departure and we hypothesized that 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'. We were concerned at the potential sexual
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implications of this ritual. Even if sexual abuse had not taken place there appeared to be
a confusing dynamic for Mary who may have been aware of her father's need for physical
and emotional contact, but in providing this was incurring the wrath of her mother. In fact
Mrs M had made allegations to this effect but appeared to be blaming Mary as much, if
not more, than Mr M. These dynamics involving contradictory or denied sexual communications
or `double-binds' have been noted by other experienced practitioners (S. Essex,
personal communication, 2003; A. Vetere, personal communication, 2003).
When she tried to leave this situation to go to university Mary possibly worried about
both her parents, especially her father. Also, 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 needs became unbearable.
Considering alternatives
A number of the following sessions were focused on exploring the possible impact of Mr
M's experiences and on the parents' relationship. Various narratives were explored; for
example, the possibility that Mary may have been trying to keep the family together
through the anorexia; that, perhaps, by going into an institution she was being loyal to her
father by following in his footsteps; that Mary may have tried to deny her own feelings of
loss of her mother by taking a critical stance towards her; and the possibility that they all
felt they didn't deserve to have their needs met, sacrificing themselves by looking after
each other:
Therapist: What developments have occurred since the last session?
Mary: 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 thaťs
right. . . .
Mrs M: Mary said in the past she feels more secure with us apart. I don't think thaťs
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 the 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 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 relationship patterns were explored:
Therapist: (to Mr M) how does it feel that Mary is perhaps getting closer to her mother.
Mr M: I just stay out of the way, iťs OK for me
Therapist: How do you think Mary feels about this?
Mr M: She doesn't seem too bothered, she's going her own way now but we do talk
sometimes.
An attempt was made to carefully monitor the changes in Mary's ways of relating to her
parents and not to go too fast. Gradually, Mary was spending more time with her friends,
had started to work again and although still struggling with the anorexia she was managing
to avoid a re-admission to the unit.
Maintaining the therapeutic base
Some significant changes appeared to have occurred in the family. 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
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off too quickly 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 initially stated that they did not need
these and that things were greatly improved. Mrs M was particularly delighted at the
changes, Mr M was more reserved but agreed. Mary still showed some doubts but agreed
that therapy could halt. 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 did do things together and that Mary did not feel `pushed ouť
emotionally.
Discussion
An attempt has been made to outline some developments in attachment theory, particularly
the exciting work exploring attachment narratives. It has been suggested that this
offers a way of linking systemic and attachment models by outlining how early experiences
lead family members to evolve different kinds of attachment narratives. In relation
to anorexia it has been suggested that the characteristic patterns of early interactions
resemble the patterns found in insecure and predominantly dismissive 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, often one or
both of the parents appear to have themselves experienced insecure attachments, as in
the case study provided. This both leads them to engage with their infants in certain ways
and later makes it difficult for them to be able to talk about or reflect on this.
Some implications for therapy have been discussed, but one of particular importance
is that, despite acknowledging the parenťs 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 history. This can imply a
pessimistic view ­ a `cascade of pathology' down the generations, 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 these experiences. It is suggested that a therapeutic approach here can
effectively combine narrative and attachment approaches by helping families to start to
explore their experiences from a secure therapeutic base. This approach also aims to
foster abilities to `reflecť on their past and current relationships. Specifically, the aim is
to foster a move towards `externalizing the pasť. This involves 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 ways different from the traditions in their families.
The therapeutic context can be seen as offering a secure base from which families can
explore their attachments (Byng-Hall, 1995). In part, this can involve the therapist
offering a model, or examples, that it is safe to engage in self-reflection ­ perhaps by
inviting family members to comment on how they are feeling about the therapist,
whether they are angry with them, think the questions are irrelevant and so on. In
addition, work using the AAI suggests that families may need to practice or even gain
skills in becoming reflective. We need to think creatively about how we can help build
these skills; for example, employing the use of micro-sculpts can make the conversation
more concrete and watching videos of other families, or films, to facilitate reflection can
also be helpful. It is possible that one of the active ingredients of multi-family therapy
is that families find it easier to grasp interpersonal issues and to become more reflective
by observing other families. To be both a part of a family system and to be able to
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reflect on it is an extremely complex task, especially in the context of heightened
anxieties.
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