Assessing Eating Disorders With Attachment Theory: The Case of Alicia by Nina Bingham

Abstract: This article will identify a primary assessment need in the case of Alicia, an eating-disordered client. I will describe the measurement tool, and in what ways it can address the eating disorder. I will explain how this tool can be used as part of an ethical assessment process for eating disorders. I will describe how I would deliver the assessment results to the client, taking into consideration the client’s cultural context. I will explain and evaluate the scoring and interpretation value of this tool. Throughout, I will cite relevant American Psychiatric Association and American Counseling Association ethical guidelines as pertaining to assessments.

    Alicia is a 25 year old lesbian whose partner has prompted her to enter therapy due to her “unhealthy eating habits.” Her partner also reported that Alicia has become increasingly moody. Although her clothes hang on her frame, Alicia reports to me she is 120 pounds; I have trouble believing this. When I ask Alicia if she is concerned with her weight, she responds, “I could still stand to lose a few pounds.” Alicia is displaying body dysmorphia, a symptom of eating disorders. She also acknowledges a low self-estimation, depression and anxiety; all common to eating disorders.

    Because in clinical practice I have observed a strong and consistent correlation between eating disorders and attachment problems, I feel a trans-diagnostic assessment of both her eating affect and behavior, and her relational attachment patterns would be most helpful to diagnosis. “Treatment outcomes for individuals with eating disorders tend to be moderate. Those with attachment-associated insecurities are likely to be the least to benefit from current symptom-focused therapies” (Tasca, Ritchie, Balfour, 2011). Because “50-60% of treatment completers do not benefit from current therapy for eating disorders” (Mitchell, Agras, Wonderlich, 2007), it behooves clinicians to tailor assessments and treatments for eating disordered clients to include assessment of the attachment functioning of the client as well. “The goal of treating an eating disorder using attachment theory for psychological assessment and case formation…will likely result in better outcomes for those suffering from these particularly burdensome disorders” (Tasca, Ritchie, Balfour, 2011). In fact, current research is confirming “that women with an eating disorder have higher levels of attachment insecurity than those without an eating disorder” (Barone, Guiducci; 2009, Fonagy et al, 1996; Illing et al., 2010; Troisi et al., 2006, Ward et al., 2001).

    While I must assess the client’s presenting concern to confirm the presence of an eating disorder, I also may find it beneficial to assess the client’s attachment issues. Understanding the client’s attachment problem enables clinicians to determine the underlying etiology beneath the eating disorder diagnosis. Under the heading of diagnosis, The American Counseling Association (ACA) Code of Ethics (2005) states that: “Counselors take special care to provide proper diagnosis of mental disorders. Assessment techniques (including personal interview) used to determine client care (e.g., locus of treatment, type of treatment, or recommended follow-up) are carefully selected and appropriately used.” Certainly, assessing both the symptoms (eating disorder) and the possible etiology (attachment disorder) would be considered due diligence in diagnosis. In approaching this two-pronged assessment, first I must diagnose the suspected eating disorder, and the American Psychiatric Association (APA)’s Diagnostic and Statistical manual of Mental Disorders (DSM-IV-TR, 2000) distinguishes three categories of eating disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified. Although Binge Eating Disorder (BED) is a fourth type of eating disorder, it will not be addressed in the narrow scope of this paper. AN is characterized by a body weight at or below 15% of normal weight, and an intense fear of gaining weight. BN is recurrent binge eating followed by chewing and spitting out of food, vomiting, laxative use, diet pills and/or over-exercising. Eating disorders are most prevalent in younger women, and 1 to 4% of adult women have a diagnosable eating disorder. Often these women suffer from comorbid psychiatric disorders such as: depression, anxiety, substance use/abuse and personality disorders (Grilo,White, Masheb, 2009). Once I have assessed and diagnosed the eating disorder, then I can look into the etiology, or causes for its development. Theories on etiology of eating disorder development include: a predisposition of low body weight in the case of AN (Bulick, Slof-Opt Landt, van Furth, Sullivan, 2007), or high body weight in the case of BN or BED (Williamson, Zuclear, Martins, Smeets, 2004). These genetic factors combined with social pressure to be thin, and idealization of thin people occurs in the early teen years, and escalates into disordered thought and behavior about eating. Added to these causes are what Fairburn et al. (2003) identified as factors common to both eating disordered individuals and those with attachment disorders: affect intolerance, interpersonal problems, low self-esteem, and clinical perfectionism. Given the striking similarities between eating disorders and attachment disorder symptoms, an assessment to discover attachment problems could be administered. Attachment to others forms, “the basis of the way in which individuals interact with the world, regulate affect, and cope with distress” (Bowlby, 1988). If the client has had a secure attachment to parents in childhood, a secure base is formed on which to form healthy personal and relational development. However, if there has been disruption in the parent-child bond in childhood, this can be reflected in unhealthy relations with self and/or others. In the case of an eating disorder, the patient has retroflected, or turned in upon themselves the anger and resentment they are carrying. Instead of expressing it outwardly, they punish themselves by restricting their food intake, or by purging after binging. In this way, they are also able to prove to themselves that they and they alone can control their lives. It is a way of maintaining control…but to their own detriment. “Chronic unaware retroflection is an interruption to contact and usually develops when the expression of aggressive feelings is perceived as dangerous. The need to express anger does not disappear, it has to go somewhere. So, without realizing what he is doing, the child may prematurely close the gestalt (unfinished business) by turning the anger against himself. If he persists in this ‘solution’ even when the circumstances change and no one threatens him, his behavior has become fixed, and retroflection may become chronic and unaware. So now when he begins to feel anger, he automatically stops feeling, and hurts himself in some way” (Perls, 1947). To interrupt this cycle of broken relational contact, self-punishment and internal over-control, the psychotherapist can focus on attachment functioning of the client.

    To assess both eating disorders and attachment, Main (2003) provides the Adult Attachment Interview Protocol (AAI), a self-report interview. “With AAI, one can assess attachment states of mind (e.g., insecurity, disorganization) and attachment functioning (e.g., coherence of mind, reflective functioning) that may not be available to consciousness.” In a pilot study using the AAI, “sixty eating disordered clients were assessed, and results showed potential benefits of using the AAI coding system scales in addition to the main classifications in order to understand better the developmental issues involved in these (eating) disorders” (Barone, Guiducci, 2009). In addition to the AAI’s validity in assessment of etiology of eating disorders, Obegi (2011) states, “The AAI is among the most important research instruments in developmental and clinical psychology. Although the details of its administration and scoring are known only to certified coders and examples of its clinical utility are, for everyday application, difficult to find, in “Clinical Application of the Adult Attachment Interview” (Steele, 2008), the authors fill a critical gap in the clinical literature on attachment; I am not aware of another book that offers how the AAI is constructed or coded, and the interview can be used as a clinical tool. Outside of the expensive, labor-intensive AAI trainings given around the world, this volume may be as close as many of us will get to the means to appreciate, learn, and use the AAI in practice…The editors are attachment researchers and well-versed in the AAI…this volume is best suited to those already acquainted with attachment theory…it will help clinical graduate students tune their ears to attachment-informed ways of listening and thinking.” In regards to limits of competence in assessment, the American Counseling Association (ACA) Ethical Code states, “Counselors utilize only those testing and assessment services for which they have been trained and are competent” (E2a, 2005), and, “Counselors are responsible for the appropriate application, scoring, interpretation, and use of assessment instruments relevant to the needs of the client, whether they score and interpret such assessments themselves or use technology or other services” (E2b, 2005). Obegi (2009) advises, “Although the AAI questionnaire is available online, scoring requires a certified trainer, or a (mental health) clinician can score the organization of mental states, coherence of mind, and reflective functioning scales.” In regards to scoring of assessments, the ACA (2005) offers the following ethical guideline: “Counselors responsible for decisions involving individuals or policies that are based on assessment results have a thorough understanding of educational, psychological, and career measurement, including validation criteria, assessment research, and guidelines for assessment development and use” (E2c, 2005). It is my opinion that a psychotherapist, if trained extensively in both human development and psychometrics, could accurately interpret the AAI with the assistance of Steele’s (2008) aforementioned text. However, what is troubling is the lack of availability of construction information and reliability test measurements. The AAI Protocol found on the internet offers no psychometric validity or reliability measures. One assumes the AAI’s psychometrics to be divulged to certified coders only, which makes the widespread clinical use of the AAI dubious, if impossible. In regards to explaining to clients the interpretation of results from the AAI,the ACA advises,“Prior to assessment, counselors explain the nature and purposes of assessment and the specific use of results by potential recipients. The explanation will be given in the language of the client (or other legally authorized person on behalf of the client), unless an explicit exception has been agreed upon in advance. Counselors consider the client’s personal or cultural context, the level of the client’s understanding of the results, and the impact of the results on the client” (E3a, 2005). In light of the AAI’s lack of published psychometrics, as a matter of ethics, the administrator should advise the client (before the assessment) that she will be evaluating and scoring the test based upon an empirically-reviewed text, and not the coding training that the test author recommends.

    The administrator should also be trained in cross-cultural studies, as interpreting the AAI will be subjective, and the administrator’s cultural bias could interfere with accurate test results. In Alicia’s case, she is a partnered lesbian. Her partner cared enough to intervene, asking Alicia to begin therapy. Since her partner has shown this level of concern for Alicia’s well-being, and since they consider themselves partners, the culturally-sensitive response from a counselor would be to ask Alicia if she thinks it would be a good idea to invite her partner into future therapy appointments, for the purpose of psychoeducating them both about the eating disorder, and to equip Alicia’s partner to support Alicia’s recovery from home.

    In the Case of Alicia who presented in therapy undiagnosed and possibly in denial about her eating disorder, assessing both the eating disorder symptoms and her attachment history could produce improved outcomes for her. “Treatment of eating disorders could be improved with a dual focus on eating disorder symptoms and on attachment functioning…being attuned to attachment functioning allows therapists to aim their therapeutic interventions at key factors that maintain the eating disorder and complicate therapeutic relationships” (Obegi, 2011). However, I feel that the empirical literature and ethical guidelines recommend that only clinicians with a thorough understanding of mental health diagnostics, attachment theory and application, and the Steele’s (2008) text should attempt to utilize the AAI.

References: Tasca, G.A., Ritchie, K., Balfour, L. (2011). Implications of attachment theory and research for the assessment and treatment of eating disorders. Psychotherapy, Vol. 48 (3). Special Section: Attachment Style and Psychotherapy. Pp. 249-259. American Psychological Association.

Mitchell, J.E., Agras, S., Wonderlick, S. (2007). Treatment of bulimia nervosa: Where are we and where are we going? International Journal of Eating Disorders, 40, pp. 95-101.

Barone, L., Guiducci, V. (2009). Mental representations of attachment in eating disorders: A pilot study using the Adult Attachment Interview. Attachment and Human Development, 11, pp. 405-417.

Fonagy P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Matoon, G., Gerber, A. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Consulting and Clinical Psychology, 64, pp. 22-31.

Illing, V., Tasca, G.A., Balfom, L., Bissada, H. (2010). Attachment insecurity predicts eating disorder symptoms and treatment outcomes in a clinical sample of women. Journal of Nervous and Psychological Problems.

Troisi, A., Di Lorenzo, G., Alcini, S., Nanni, R.C., Pasquali, C., Siracusano, A. (2006). Body dissatisfaction in women with eating disorders: Relationship to early separation anxiety and insecure attachment. Psychosomatic Medicine, 68, pp. 449-453.

Ward, A. Ramsay, R., Turnbull, S., Steele, H., Treasure, J. (2001). Attachment in anorexia nervosa: A transgenerational perspective. British Journal of Medical Psychology; 74, pp. 497-505.

American Counseling Association Governing Counsel. (2005). ACA Code of Ethics. Retrieved from: www.counseling.org

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Fourth Edition. Text Revision. Arlington, Virginia.

Grilo, C.M., White, M.A., Misheb, R.M. (2009). DSM-IV Psychiatric disorder comorbidity and its correlates in binge eating disorder. International Journal of Eating Disorders, 42, pp. 228-234.

Bulick, C.M., Slof-Op’t Landt, M.C., van Furth, E.F., Sullivan, P.F. (2007). The genetics of anorexia nervosa. Annual review of nutrition, 27, pp. 263-275.

Williamson, D.A., Zuclear, N.L., Martin, C.K., Smeets, M.A. (2004). Etiology and management of eating disorders. In H.E. Adams and P.B. Sutker (Eds.), Comprehensive psychopathology (3rd ed., pp. 641-670). New York: Springer.

Fairburn, C.G., Cooper, Z., Shafran, R (2003). Cognitive behavior therapy for eating disorders: A “transdiagnostic” theory and treatment. Behavior Research and Therapy, 41, pp. 509-528.

Bolby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York: Basic Books.

Perls, F. S. (1947). Ego, Hunger and Aggression: A revision of Freud’s Theory and Method. The Gestalt Journal Press, Highland, New York.

Main, M. (2003). Adult attachment interview protocol (AAI). Retrieved from www.psychology.sunysb.edu/attachment/measures/content/aai_interview.pdf

Obegi, J.H. (2011). Review of “Clinical applications of the adult attachment interview.” Psychoanalytic Psychology, Vol 28 (1), pp. 162-163. US: Educational Publishing Foundation. A Psych A.

Steele, H & M. (2008). Clinical Application of the Adult Attachment Interview. New York: Guilford Press, p. 501.