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Psychotherapy
2011, Vol. 48, No. 3, 249 –259
© 2011 American Psychological Association
0033-3204/11/$12.00 DOI: 10.1037/a0022423
PRACTICE REVIEW
Implications of Attachment Theory and Research for the Assessment and
Treatment of Eating Disorders
Giorgio A. Tasca
Kerri Ritchie
The Ottawa Hospital, Ottawa, Ontario, Canada, and
University of Ottawa
The Ottawa Hospital, Ottawa, Ontario, Canada
Louise Balfour
The Ottawa Hospital, Ottawa, Ontario, Canada, and University of Ottawa
In this paper, we review the research literature on attachment and eating disorders and suggest a
framework for assessing and treating attachment functioning in patients with an eating disorder.
Treatment outcomes for individuals with eating disorders tend to be moderate. Those with attachmentassociated insecurities are likely to be the least to benefit from current symptom-focused therapies. We
describe the common attachment categories (secure, avoidant, anxious), and then describe domains of
attachment functioning within each category: affect regulation, interpersonal style, coherence of mind,
and reflective functioning. We also note the impact of disorganized mental states related to loss or
trauma. Assessing these domains of attachment functioning can guide focused interventions in the
psychotherapy of eating disorders. Case examples are presented to illustrate assessment, case formulation, and group psychotherapy of eating disorders that are informed by attachment theory. Tailoring
treatments to improve attachment functioning for patients with an eating disorder will likely result in
better outcomes for those suffering from these particularly burdensome disorders.
Keywords: attachment, eating disorders, psychological assessment, group psychotherapy
During the past 30 years, attachment theory (Bowlby, 1980)
has emerged as one of the most important conceptual frameworks for understanding affect regulation and human relationships (Mikulincer & Shaver, 2007). Also, during that period,
research on eating disorders has been increasing (Theander,
2004). However, attachment theory is only recently being applied to research on eating disorders (e.g., Illing, Tasca, Balfour, & Bissada, 2010). The goal of this practice review is to
conceptualize eating disorder treatment using attachment theory, and to orient clinicians to use attachment theory for the
psychological assessment, case formulation, and psychotherapy
of individuals with an eating disorder.
There are three main diagnostic categories of eating disorders,
namely, anorexia nervosa (AN), bulimia nervosa (BN), and eating
disorders not otherwise specified (American Psychiatric Association [APA], 2000). AN is characterized by maintaining body
weight at or below 15% of the normal value, and an intense fear of
gaining weight. BN is characterized by recurrent binge eating,
followed by inappropriate compensatory behaviors (e.g., vomiting). Eating disorders not otherwise specified is a category for
individuals who do not meet specific criteria for AN or BN but
who exhibit significant eating disorder symptoms (e.g., binge
eating with no purging, i.e., binge eating disorder [BED]). Eating
disorders occur predominantly in women, such that approximately
1%– 4% of adult women have a diagnosable eating disorder (APA,
2000). These individuals often suffer from comorbid psychiatric
disorders such as depressive, anxiety, personality, and substance
use disorders (Grilo, White, & Masheb, 2009). The mortality rate
for AN is the highest among all psychiatric disorders (Agras,
2001), and the eating disorders result in very high personal and
economic burden (Grenon et al., 2010).
Current theories of the development of an eating disorder
include the interaction of the following factors: a predisposition
for low body weight in the case of AN (Bulik, Slof-Op’t Landt,
van Furth, & Sullivan, 2007), or high body weight in the case
of BN and BED (Williamson, Zucker, Martins, & Smeets,
This article was published Online First May 23, 2011.
Giorgio A. Tasca, Department of Psychology, The Ottawa Hospital,
Ottawa, Ontario, Canada, and Department of Psychiatry, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Kerri Ritchie, Department of Psychology, The Ottawa Hospital; Louise Balfour, Department
of Psychology, The Ottawa Hospital, and Division of Infectious Diseases,
Faculty of Medicine, University of Ottawa.
This practice review presents two case examples that are amalgamations
of a number of patients seen over many years, and not representative of
particular individuals. The initials used to refer to a case and the details
provided in the examples in no way could be used to identify a specific
person.
Correspondence concerning this article should be addressed to Giorgio
A. Tasca, The Ottawa Hospital, 501 Smyth Road Box 400, Ottawa, ON,
Canada, K1H8L6. E-mail: gtasca@toh.on.ca
249
TASCA, RITCHIE, AND BALFOUR
250
2004); social pressures to be thin and thin-ideal internalization
(Stice, 2001) that give rise to dieting in early teens as a
precursor to emotional disinhibited eating (Polivy & Herman,
1985); and body dissatisfaction (Stice, 2001). This has led to
the development of cognitive behavioral therapy (CBT) models
to explain the development, maintenance, and treatment of
eating disorders (e.g., Wilson & Fairburn, 1993). Such models
emphasize treating restrained eating, disinhibited eating, and
weight and shape concerns (Fairburn, Cooper, & Shafran,
2003).
Despite flourishing research on treatments focused on these
factors (Wilson & Fairburn, 2002), 50%– 60% of treatment completers in clinical trials do not benefit from current therapies for
eating disorders (Mitchell, Agras, & Wonderlich, 2007). As a
result, Fairburn et al. (2003) identified additional maintenance
factors for some individuals with eating disorders who might not
respond to conventional treatments. These additional maintenance
factors include affect intolerance, interpersonal problems, low
self-esteem, and clinical perfectionism. These factors represent
themes that are in common with attachment theory.
Attachment Theory
Attachment is an inborn system that motivates an infant to
seek proximity to a caregiving adult. These initial proximityseeking attachment behaviors result in repeated interactions
with a caregiver that become encoded in the implicit memory
system, which in turn become internal working models of
attachments that act as schemata for future relationships (Siegel, 1999). These internal working models form the basis of
styles using which individuals interact with the world, regulate
affect, and cope with distress (Bowlby, 1988). As such, attachment theory has implications for the treatment of individuals
with emotional problems, including eating disorders.
Attachment security occurs in 55% of the population, and
insecurity occurs in 45% of the population (BakermansKranenburg & vanIjzendoorn, 2009). These attachment states
are remarkably stable across the life span (Waters, Merrick,
Treboux, Crowell, & Albersheim, 2000). However, studies have
also found that attachment is malleable, such that, with new
experiences (e.g., adult trauma, psychotherapy), an individual
can move from insecure to secure states or vice versa throughout their life (Bakermans-Kranenburg & vanIjzendoorn, 2009;
Waters et al., 2000).
Although attachment was originally assessed in children (Ainsworth, Blehar, Waters, & Wall, 1978), it was extended to adults
using the Adult Attachment Interview (AAI; Main, Goldwyn, &
Hesse, 2003), which categorized adults as secure, preoccupied
(i.e., anxious), or dismissing (i.e., avoidant). Disorganized (or
unresolved) states associated with loss or trauma can also be
evaluated across the attachment categories. Concurrently, selfreport measures of attachment were developed to assess interpersonal style that is associated with affect regulation (Mikulincer &
Shaver, 2007). Within each of the common attachment categories
(e.g., secure, anxious, avoidant), one can concurrently describe
areas of attachment functioning, that is, affect regulation, interpersonal style, coherence of mind, and reflective functioning.
Attachment Categories and Functioning
Attachment Security
Adults with secure attachments do not feel easily threatened, are
able to effectively regulate their affect, and thus rarely engage in
intense self-blame and self-criticism (Fuendeling, 1998). The interpersonal style of securely attached adults is characterized by
adaptively seeking support in relationships and desiring intimacy
and closeness with others (Mallinckrodt, 2000). These individuals
are also able to develop an autonomous or coherent mind with
which they can evaluate attachment experiences as they occur
(Main et al., 2003). That is, they are consistent, organized, and
mindful of the current context when they recall and discuss their
emotions and their attachment relationships. Those who are securely attached are able to identify their own feelings; consider
others’ potential reactions, feelings, and needs; and think through
cause and effect. The capacity to manage all these internal processes is necessary for reflective functioning (Allen, 2005; Crittenden, 2006). Owing to reflective functioning, their capacity to
“mentalize” operates unconsciously, yet effectively (Allen, 2005).
Attachment Avoidance
Those with avoidant attachments (i.e., dismissing) do not expect
that expressing their affect and seeking proximity will result in
positive outcomes. They have learned that vulnerability results in
behaviors from attachment figures that provoke a worsening of the
emotional experience (Fuendeling, 1998; Mikulincer, Shaver,
Sapir-Lavid, Avihou-Kanza, 2009). In order to cope and maintain
some level of affect regulation, they prefer to avoid such situations. Thus, they create a defensive memory structure in which
they have little accessibility to painful memories (Fraley & Shaver,
2000), and they use emotional distancing strategies characterized
by deactivation or downregulation of emotions (Fonagy, 2001).
Despite their high levels of threat appraisal (Dozier & Kobak,
1992; Roisman, Tsai, & Chiang, 2004), they are often unable to
identify emotions in themselves and others (Siegel, 1999). In cases
when they cannot avoid emotion in relationships, they may become overwhelmed and their deactivating strategies may breakdown resulting in displays of anger (Crittenden, 2006).
In terms of interpersonal style, attachment-avoidant individuals
believe that the world is dangerous, and others cannot be trusted to
care for them without hurting them. Therefore, such individuals
tend to be overly self-reliant and avoid needing others in order to
maintain independence, control, and uniqueness (Shaver & Mikulincer, 2002). They often have an impoverished recollection of
their childhood and attachment-related experiences (Siegel, 1999).
Some may idealize or be derogatory toward attachment figures, but
lack examples or details to support this view (Main et al., 2003).
As such, their coherence of mind is poor. Their defensive memory
structure makes it difficult to consider their internal experiences or
those of others. Thus, reflective functioning of these individuals is
limited (Wallin, 2007).
Attachment Anxiety
Those with attachment anxiety (i.e., preoccupied) have poor
self-regulatory skills (Mikulincer et al., 2009). They are often able
SPECIAL SECTION: IMPLICATIONS OF ATTACHMENT THEORY
to identify their own negative affect, but it is an exaggerated
perception (Mikulincer & Florian, 1998). Research on affect regulation found that anxiously attached individuals readily and repeatedly reaccess painful attachment-related memories, thereby
maintaining their constant agitated state (Mikulincer, 1995).
These hyperactivating strategies that upregulate the emotional
system keep the individual hypervigilant with respect to relationship losses. The interpersonal style of the anxiously attached is
characterized by intense focus on relationships, and by attempts to
control their anxiety by minimizing emotional distance and soliciting constant displays of support, love, and care from others
(Bartholomew & Horowitz, 1991). Even if this hyperfocus manifests as compulsive caretaking, they pay excessive attention to
their own needs at the expense of others (Bartholomew & Horrowitz, 1991). An individual with an anxious attachment will
perceive slight irritation in others as rejection (Jurist & Meehan,
2008).
Those with attachment anxiety are unable to make orderly sense
of their past experiences (Foscha, 2000). Recalling their past
experiences often results in a disconnected flow of associations,
which may seem to be rambling, shifting in focus (i.e., off-topic,
not concise, switching perspective), and not taking into account the
demands of the current context. These indicate low coherence of
mind. Further, the anxiously attached individual may become
overly preoccupied and immersed in past attachment losses or
slights (Main et al., 2003). As a result, they tend to focus on their
feelings to guide their behaviors and may avoid thinking of consequences. These processes, along with the difficulty in keeping in
mind the needs and affects of others, indicate problems with
reflective functioning.
Disorganized States of Mind
Along with secure, avoidant, or anxious attachments, individuals may experience disorganized (i.e., unresolved) attachment
states of mind. Disorganized mental states may result when parenting is confusing, frightening, or abusive, or when there is a loss
of an attachment figure. Unable to find a strategy with which they
can safely engage their primary caregivers, these children react to
distress with apparently incompatible behaviors (e.g., seeking and
avoiding contact) (Lyons-Ruth & Jacobovitz, 1999). As adults,
they show disturbances in cognition and emotion surrounding their
loss or trauma, including absorption, guilt, and/or dissociation
(Steele, Steele, & Murphy, 2009). Thus, disorganized states are
associated with childhood adversity, including abuse, neglect, or
loss of an attachment figure (Bakermans-Kranenburg & van Ijzendoorn, 2009).
Attachment and Eating Disorders
As indicated earlier, research on attachment functioning and
eating disorders is small but growing. The research to date indicates 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). Further, research indicated
that attachment anxiety was associated with greater eating disorder
symptoms and poorer treatment outcomes, even after controlling
for differences between eating disorder diagnostic groups (Illing et
251
al., 2010). In other words, knowing about a patient’s attachment
insecurity adds to understanding their symptoms and to predicting
treatment outcomes above and beyond what we learn from their
specific eating disorder diagnosis. In two separate samples, our
research team found that high attachment anxiety was associated
with poorer outcomes in group CBT for those with BED (Tasca et
al., 2006) and in structured day treatment for AN (Illing et al.,
2010). Conversely, high attachment anxiety was associated with
better outcomes for individuals with BED, when they received a
group psychodynamic treatment (Tasca, Mikail, & Hewitt, 2005)
that specifically focused on affect regulation and interpersonal
problems (Tasca et al., 2006). In addition, higher attachment
avoidance was associated with dropping out of day treatment for
patients with AN (Tasca, Taylor, Bissada, Ritchie, & Balfour,
2004), and group CBT for those with BED (Tasca et al., 2006).
Therefore, treatment for eating disorders that focuses on attachment functioning may mitigate dropping out for those with attachment avoidance and improve outcomes for those with attachment
anxiety. Keeping this in mind, in this practice review, we focus on
research of four domains of attachment functioning (affect regulation, interpersonal behaviors, coherence of mind, and reflective
functioning) in eating disorders.
Affect Regulation
Emotion-focused coping (Perry, DiTommaso, Robinson, & Doiron, 2007), emotion deactivating strategies (Cole-Detke & Kobak,
1996), and general difficulty in regulating affect tend to be associated with eating disorder cognitions, symptoms, and problematic
eating. One could argue that attachment insecurity may contribute
to the development of maladaptive affect regulation strategies,
which in turn may result in the expression of eating disorder
symptoms. Research by our team provided some evidence for this
hypothesis (Tasca et al., 2009). We found that the association
between attachment anxiety and both eating disorder and depressive symptoms was mediated by emotional reactivity, and the
association between attachment avoidance and depressive symptoms in patients with an eating disorder was mediated by cutting
off emotions. In other words, patients with an eating disorder and
attachment anxiety experience hyperactivation of their emotions
that may result in symptoms such as binging or purging, perhaps
as a way of coping. Conversely, those with attachment avoidance
cut off emotional experience, and this may be enabled by their
extreme dietary restriction.
A therapist working with a patient with an eating disorder and
attachment anxiety might consider interventions to highlight the
association between the hyperactivation of emotions and eating
disorder symptoms that are used to manage the intense emotional
experience. The therapist could encourage the development of
other strategies to downregulate the affect (e.g., Therapist: You
described a link between becoming upset or angry and then binge
eating. So part of our work together will involve helping you to
become more aware when that happens in the moment, and to help
you to get some distance from your emotions so that you won’t
need to binge as a way of getting relief from feeling overwhelmed).
Conversely, a therapist may encourage a patient with an eating
disorder and attachment avoidance gradually to become less cut
off from their emotions (e.g., Therapist: It seems to me that you
have a hard time identifying what you are feeling, and when you
252
TASCA, RITCHIE, AND BALFOUR
do it’s scary. I understand that controlling your eating helps to
keep your emotions out of awareness. So, it might be helpful if we
start to put words to what you are feeling, and to figure out why
you have these feelings. Eventually, once you become comfortable
with that, you might find it easier to relax your control over what
you eat).
Interpersonal Style
The interpersonal sensitivities of those with eating disorders
most likely have their origin in problems with autonomy and
separation from parents, and these may be factors in the development and maintenance of an eating disorder (Ringer & Crittenden,
2007). Not surprisingly, there is also evidence that individuals with
an eating disorder have problems with interpersonal interactions
that parallel avoidant or anxious attachment styles (Illing et al.,
2010; Tasca et al., under review). These interpersonal problems
and a history of problematic relationships may confer heightened
sensitivity to separation and loss. Steiger, Gauvin, Jabalpurwala,
Séguin, and Stotland (1999) found that women with bulimic symptoms were intrinsically hypersensitive to negative social interactions, which in turn resulted in heightened self criticism and
negative mood. Importantly, binge eating symptoms were often
immediately preceded by negative social interactions and selfcriticism. These studies suggest that individuals with an eating
disorder may be sensitive to separation and loss, and then attempt
to manage relationships by dismissing (for those with attachment
avoidance) or by being highly preoccupied (for those with attachment anxiety). An avoidant/dismissing style may lead to greater
isolation and separation, whereas an anxious/preoccupied style
may lead to experiences conflict in relationships and fears of
abandonment. Each outcome could lead to negative affect, self
criticism, and then binge eating in bulimic individuals. As suggested by Steiger et al. (1999), binge eating symptoms progressively consolidate existing interpersonal and self-image problems,
thus perpetuating a cyclical pattern.
For a patient with an eating disorder and attachment anxiety, a
therapist might highlight the relational pattern in which a negative
interaction precedes self-criticism and then binge eating (e.g.,
Therapist: This isn’t the first time that an argument with your
mother led to a binge. It seems that the fear of your mother
rejecting you after a fight and how badly you feel about yourself
causes you to binge. We’re going to work on helping you become
your own person without needing to fight your mom, and not being
so worried that she’ll abandon you if she’s unhappy with your
decisions.). The goal of such an intervention is to encourage more
adaptive interpersonal interactions (e.g., asserting one’s needs
without fighting) and self-concepts (i.e., not blaming oneself for
mother’s unhappiness) that might precede eating disorder symptoms.
Coherence of Mind
Using the AAI, Fonagy et al. (1996) reported that a mixed group
of patients with an eating disorder had similar levels of coherence
of mind as compared with other Axis I diagnostic groups, but
significantly lower coherence as compared with a nonpsychiatric
control group. Similarly, Barone and Guiducci (2009) reported
significantly lower coherence of mind for a sample of women with
an eating disorder as compared with a normative sample. Ward and
colleagues found that patients with AN had significantly lower
coherence of mind as compared with others with an eating disorder, suggesting that women with AN may particularly have difficulty in constructing a coherent narrative of themselves and their
experiences. Poor coherence of mind in a patient with an eating
disorder might result in difficulties in creating a narrative about
their own psychological development, understanding the place of
eating disorder symptoms in their life, and being able to establish
a collaborative relationship in therapy.
Often, patients with an eating disorder struggle to provide a
realistic and consistent appraisal of their development and relationships with attachment figures. With an avoidant patient who
has a dismissing or idealizing representation of a parent, a therapist
might encourage a richer and more detailed narrative by gently
noting inconsistencies (e.g., Therapist: In the past you insisted that
your parents were perfect, but today you described how uncontrollably angry your father was when you didn’t do well in the
competition. Is it possible that as you are getting healthier you are
becoming more able to clearly see your parents including their
flaws?). With an anxiously attached patient who is preoccupied
and angry, a therapist may highlight how anger at a parent, for
example, interferes with the patient’s ability to collaborate with the
therapist (e.g., Therapist: I asked you about your childhood relationship with your father, but instead you’ve been telling me about
how angry you are at your mother’s dieting. You are so caught up
with being angry at your mother that it interferes with our ability
to talk about anything else. Tell me again about your father, and
this time I’ll help you stay focused).
Reflective Functioning
The research on reflective functioning in eating disorders is in
its early stages. There is related literature available on the theory
of mind in AN. Russell, Schmidt, Doherty, Young, and Tchanturia
(2009) found that affective theory of mind (i.e., unconscious
decoding of others’ emotions without cognitive deduction) was
impaired in patients with AN as compared with controls, and that
this impairment was independent of AN severity (i.e., degree of
low body weight). Thus, the difficulty experienced by those with
AN in unconscious processing of others’ emotions may be associated with an underlying vulnerability to AN, which is not explained by the effects of starvation on cognitive functioning. In the
only study to date that directly assessed reflective functioning in a
mixed sample of individuals with an eating disorder, Fonagy et al.
(1996) reported that patients with an eating disorder had significantly lower reflective functioning scores on the AAI as compared
to those with other Axis I disorders (i.e., depression, anxiety,
substance abuse) and to a nonclinical group. These results indicated that a greater deficit in reflective functioning is a distinct
characteristic of those with an eating disorder. The difficulty in
depicting the thoughts and feelings in oneself and in others limits
the ability of a patient with an eating disorder to engage in intimate
relationships and to make use of psychotherapy.
Poor reflective functioning in patients with an eating disorder
might be manifested by a sparse or limited understanding of their
own and others’ thoughts and emotions. Discussing patients’ internal experiences as they occur in group therapy might be useful
in encouraging greater reflective functioning. In the following
SPECIAL SECTION: IMPLICATIONS OF ATTACHMENT THEORY
example, the therapist uses the interaction between two group
members, Judy and Alex, to promote reflective functioning in
Judy:
Therapist: (to Judy) How do you understand what Alex is feeling
right now about you?
Judy: I don’t know. I don’t think she’s comfortable with me.
Alex: Actually, I’m scared for you. I worry that your purging is
out of control and that you might die.
Judy: You have a good heart; you care for all of us.
Therapist: (to Judy) She’s talking about you right now. How do
you think she’s feeling about you?
Judy: She’s afraid for me. (To Alex) I’m so sorry that I’m
worrying you.
Attachment Informed Assessment and Psychotherapy
of Eating Disorders
We start this section by outlining a process of assessment for the
eating disorders that focuses on attachment functioning. We look
at the self-report measurement of attachment with the Experiences
in Close Relationships scale (ECR; Brennan, Clark, & Shaver,
1998) and an interview-based assessment with the AAI (Main et
al., 2003). The ECR assesses consciously available representation
of one’s interpersonal style, which in turn is associated with affect
regulation. With the 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. A combination of these two approaches will
provide the clinician with valuable attachment-related information
about the patient with an eating disorder.
The ECR is an easy to use and freely available 36-item selfreport questionnaire of romantic attachment (Brennan et al., 1998)
that yields two dimensional scales of attachment avoidance and
attachment anxiety. The ECR has excellent psychometric properties, including a relatively low correlation between its two dimensional scales. However, the ECR requires participants to be in a
current romantic relationship, or to respond to items as if in a
relationship. This may be a challenge for younger patients or for
those who have never dated. Although no formal norms are available, interpretation of ECR scores is aided by published studies of
nonclinical samples of women (e.g., Shaver, Schachner, & Mikulincer, 2005). Table 1 provides ECR item means and standard
deviations for nonclinical and eating disorder samples. Scores that
are one standard deviation higher than a nonclinical sample mean
might suggest at least moderate problems with attachment anxiety
or avoidance.
The AAI is the gold standard for assessing attachment states of
mind. In the interview, the participant is asked to recall and
describe attachment-related memories from early childhood and to
evaluate these from the current adult perspective. There are also
questions about experiences of abuse and loss. The AAI coding is
primarily based on the thoughtfulness and coherency with which
adults are able to describe their childhood experiences of attachment figures and their effects. AAI questions are available online
(Main, n.d.), but reliable scoring of the AAI requires intensive
training by certified trainers and achieving 80% reliability on
practice transcripts. Such training is necessary to use the AAI in a
research context. A trained clinician attuned to particular aspects
of patients’ discourse defined by the AAI could assess for disor-
253
ganization of mental states, coherence of mind, and reflective
functioning.
Rating coherence of the AAI transcript is based on Grice’s
(1989) discourse analysis in which four maxims of coherent conversation are described: truth, relation, economy, and manner. In
the AAI, truth and relation are satisfied when there is a clear fit
between semantic descriptors (such as adjectives to describe childhood relations with parents) and the individual’s ability to provide
specific, consistent, and relevant narrative that suggest credibility
of the content. Economy is satisfied when the participant gives an
adequate amount of information. Manner is satisfied when the
interviewee is collaborative and descriptors of events are contained
(i.e., not using jargon, meaningless phrases, or actively angry
speech). Reflective functioning in the AAI (Fonagy et al., 1996) is
defined as awareness of: (1) mental states in self and others, (2) the
mutual influences of mental states and behaviors, (3) a developmental perspective in one’s life, and (4) sensitivity to the current
conversational context. Reflective functioning is evidenced by the
interviewee providing thoughtful reflection to AAI questions such
as “why did your parents behave the way they did during your
childhood?”, and “how do you think your childhood experiences
affect your adult personality?” Disorganized (unresolved) states
may be evident in AAI responses to questions about loss and
abuse. These individuals may become disorganized in their narrative around the loss or abuse, or become absorbed, and so are
unaware of the conversational context, or make errors in logic,
timing, or sequencing of events when recalling the trauma or loss
(Steele et al., 2009).
Table 1 provides means and standard deviations of AAI coherence of transcript and reflective functioning scale ratings for
nonclinical and eating disorder samples. Scale scores range from
⫺1 to 9 for reflective functioning (Fonagy, Target, Steele, &
Steele, 1998) and 1 to 9 for coherence (Main et al., 2003). Typically, scores of ⱕ4 indicate a deficit and scores of ⱖ5 indicate at
least adequate functioning.
Case Example 1: Assessment of JK
JK is an 18-year-old woman referred for an assessment and
treatment of an eating disorder. She is severely underweight with
a body mass index (BMI) ⫽ 17.0. BMI is a ratio of weight in
kilograms divided by height in meters squared. A BMI of ⬍17.5 is
a common criterion for AN in adults, a BMI of ⬍18.5 indicates
underweight, and a BMI of ⬎25 indicates overweight (WHO,
2006). JK believes that parts of her body are “fat,” restricts her
food intake to lose weight, is driven to be thin, has secondary
amenorrhea, but does not binge or purge. Therefore, she meets
diagnostic criteria for restricting-type AN. She was a star amateur
athlete and is self-described as being a perfectionist, but she has
been unable to compete recently because of a recurring injury and
fatigue, and her excellent school grades are slipping. The eating
disorder symptoms started at the age of 13, shortly after her
mother’s death owing to an illness. JK claims to have grieved
her mother’s death, but JK and her father avoid talking about her
mother. JK admitted to repeated arguments with her father, but
there is no history of abuse, and she claims that her childhood was
“perfect.” She has several friends and dated in the recent past, but
admitted to never being very close or emotionally intimate in
relationships, and this bothers her.
TASCA, RITCHIE, AND BALFOUR
254
Table 1
Means and Standard Deviations of Attachment Self-Report and Interview Scales for Nonclinical and Eating Disorder Samples
ECR scale
AAI
Anxiety
Avoidance
Reflective
functioning
Coherence
Samples
M
SD
M
SD
M
SD
M
SD
Nonclinical
AN
BN
Eating disorders
3.55
4.19
4.36
4.26
1.10
1.25
1.29
1.24
2.03
3.55
3.93
3.76
0.72
1.38
1.28
1.25
5.5
2.3
NA
4.1
1.4
1.1
NA
1.6
5.2
2.4
NA
2.8
1.5
1.6
NA
1.7
Note. For the ECR scale: nonclinical sample of women, N ⫽ 72, is from Shaver et al., 2005; AN ⫽ anorexia nervosa, N ⫽ 74; BN ⫽ bulimia nervosa,
N ⫽ 138; and mixed eating disorder diagnoses, N ⫽ 310, are not previously published data, but the samples are described in Tasca et al. (2009). AAI
nonclinical data, N ⫽ 85, and mixed eating disorder sample data, N ⫽ 14, are from Fonagy et al. (1996). AAI AN sample, N ⫽ 20, is from Ward et al.
(2001). M ⫽ means; SD ⫽ standard deviations; ECR ⫽ Experiences in Close Relationships scale; AAI ⫽ Adult Attachment Interview; NA ⫽ data not
available.
The ECR indicated an avoidant attachment style, such that JK
scored more than two standard deviations above the norm on the
attachment avoidance scale and within the norm on the attachment
anxiety scale. Her interpersonal style, as self-reported on the ECR,
was characterized by discomfort with close or intimate relationships, and so she may appear to others as critical or aloof. This is
often associated with affect regulation characterized by constrained emotional experiences and keeping emotions to oneself.
During an extended part of the diagnostic interview in which the
interviewer asked several questions from the AAI, JK’s responses
indicated problems with coherence of her narrative. When asked
for adjectives to describe her mother and father before the age of
12, JK provided adjectives that were very positive (e.g., “loving,”
“caring,” “perfect”). However, (a) the supporting examples she
provided were vague or circular (e.g., “My mother was loving
because she was caring”), thus violating the maxim of truth and
indicating idealization; (b) the responses were too brief, or she
claimed to have no specific memory, thus violating the maxim of
economy; and (c) with regard to her father, JK consistently gave
current examples despite being prompted to give examples before
the age of 12, thus violating the maxim of relevance.
Poor reflective functioning was noted when JK was asked the
following AAI questions: “why do you think your parents behaved
the way they did during your childhood?” (JK: “They are good
parents”), and “how do you think your childhood experiences
affect your adult personality?” (JK: “I don’t know, I don’t think
they do. I guess I haven’t given it much thought.”). Disorganization regarding her mother’s death was evident throughout the
interview because JK often referred to her mother in the present
tense or as if she were still living (“My mom will be disappointed
if I don’t go to university next fall”). Further, during questions
specifically about her mother’s death, JK often lost track of the
question or of the narrative sequence:
Interviewer: What were the circumstances around your mother’s death?
JK: Mmm . . . It was in the fall and I was supposed to attend a
tournament out of town . . . (5-second pause) we had an early snow
storm . . . (20-second pause) . . . what was your question again?
Interviewer: The circumstances around your mother’s death?
JK: Oh yah . . . I remember we had the funeral in our home town
because my mother loves our home town . . . .
The overall assessment highlighted several issues on which to
focus for intensive treatment of a severe eating disorder, including
nutritional rehabilitation, weight restoration, and reducing her
drive for thinness. The assessment also indicated several
attachment-related foci for psychotherapeutic interventions which,
given the treatment center, would include group therapy. JK has an
avoidant style or dismissing state of mind. Given her downregulation of emotion owing to discomfort, a gradual approach should
be taken to encourage her affective expression and experience over
the course of treatment (Wallin, 2007). Insisting that JK selfdisclose too early in therapy might result in premature termination
and/or and an escalation of dietary restriction to aid in cutting off
her affect (Tasca et al., 2004; Tasca et al., 2009). This may occur
because of her discomfort with emotions and fears related to others
hurting her if she allows herself to become vulnerable. JK’s
interpersonal style and emotional detachment may make it difficult
for her to engage fully during the initial stages in a therapy that
requires exploration of interpersonal patterns. However, this exploration is important to help her develop meaningful adult relationships, which are currently lacking. She will benefit from interpersonal feedback from other psychotherapy group members
about how she relates to others and how this keeps them at a
distance. Table 2 presents a hierarchy of interventions for a patient
with attachment avoidance and an eating disorder like JK. The
table illustrates an incremental graded exposure to affect and to
interpersonal closeness in therapy.
Regarding improving coherence of mind, JK may benefit from
reexamining her idealized evaluation of her family, and by developing a more complete and sound appraisal. This may help JK to
become more realistic with her own self-appraisal as well. With
regard to reflective functioning, JK could be encouraged to understand better her own internal experiences and their effects on her
eating disorder symptoms. Finally, regarding disorganization of
mental states with respect to her mother’s death, JK would benefit
from talking about the use of her avoidant defenses to protect her
from the impact of her mother’s death, and how these defenses
affect her eating disorder symptoms, her difficulty in connecting
emotionally with others, and her current conflicted relationship
with her father. Table 3 lists goals for treatment of an attachmentavoidant individual with an eating disorder like JK.
SPECIAL SECTION: IMPLICATIONS OF ATTACHMENT THEORY
255
Table 2
Hierarchy of Graded Therapist Interventions for a Patient With Attachment Avoidance and an Eating Disorder Like JK
Type of intervention
Examples of therapist interventions
Level 1: describing the affect
Level 2: empathic attunement to the affect
Level 3: confronting the defenses against
affect
Level 4: interpreting the affect and
interpersonal pattern
(To JK): “It looks like you are feeling sad”
(To other group members): “What do think she might be feeling?”
(To JK): “I felt sad when you said you had to give up your cat.”
(To other another group member): “You looked sad when JK talked about her cat. Can you describe
your feelings to her?”
(To JK): “It’s like I have to be perfect in what I say about your feelings. I worry that if I get it wrong,
you’ll be angry and quit therapy.”
(To other group members): “I notice that you are extra careful with JK’s feelings. I wonder if you can
tell her what you are concerned might happen if you talk freely about her feelings.”
(To JK and group): “I think that it scares you to let yourself feel sad and to be vulnerable with the
group. Being vulnerable in the past in your family hasn’t gone well for you, so I can see that doing
that with the group might feel scary for you.”
Case Example 2: Group Psychotherapy of BP
To illustrate psychotherapy of a patient with an eating disorder
that is informed by an attachment framework, we discuss the group
psychotherapy of BP. BP is a 24-year-old woman diagnosed with
purging-type BN. BP has a normal weight but binges and purges
four to six times a week, and has been doing so for at least 8 years.
She was sexually abused by her maternal grandfather on several
occasions between the ages of 8 and 12, and the abuse ended after
she told her aunt who, presumably, confronted the grandfather.
The patient’s mother was depressed from as far back as BP can
remember, and her mother often spent weeks at a time in bed
throughout BP’s childhood. Her father was most likely dependent
on alcohol, had a short temper, but otherwise was not very involved with the family. Her parents are still together and BP lives
with them. As a teenager, BP excessively used alcohol and drugs,
and often had sexual encounters while being intoxicated, and these
continued until recently. She was very sensitive to rejection and
often ended relationships because of perceived slights. With a
great deal of shame, she recounted sleeping with several girlfriends’ boyfriends, effectively ending these friendships. Although
free of alcohol and drugs for the past 3 months, she is worried that
she will relapse.
On the ECR, BP reported being too needy in relationships and
having a preoccupation with or fear of loss in relationships. This
suggests that BP has an anxious attachment that is often associated
with being easily overwhelmed by feelings, a hyperactivation of
the emotion system, and poor affect regulation. Responses to AAI
questions indicated poor coherence of mind in which she was
alternately preoccupied with self-loathing or anger toward her
mother, both of which interfered with her ability to provide a
concise and relevant narrative. Consequently, she could neither
easily describe the impact of her chronically unmet childhood
needs for affection and attention on her current functioning nor
could she appreciate the roles played by the substance abuse,
sexual acting out, and eating disorder symptoms in regulating her
emotions that often seemed to be out of control. Her reflective
functioning was impaired by her preoccupying anger that diminished her ability to appreciate others’ affective states, including her
mother’s current intentions to provide comfort, or others’ feelings
of caring for her. The childhood sexual abuse had a disorganizing
Table 3
Summary of Treatment Plans for JK With AN and BP With BN
Treatment goals
Eating disorder goals
Attachment related goals
JK: AN diagnosis with attachment avoidance
BP: BN diagnosis with attachment anxiety
● Weight restoration
● Normalized diet
● Reduced drive for thinness
Interpersonal style:
● ⌱ncrease emotional connection to others
Affect regulation:
● Upregulate emotions and reduce defenses against
affect
Reflective functioning:
● Understand own and others’ internal experiences
and effects of food restriction
Coherence of mind:
● Develop less idealized or dismissing view of parents
Disorganized mental states:
● Develop a coherent narrative about mother’s death
● Abstain from binging/purging
● Normalized eating pattern
● Reduced body dissatisfaction
Interpersonal style:
● Reduce fears of loss and abandonment
Affect regulation:
● Downregulate emotions to more effectively
regulate intense affect
Reflective functioning:
● Appreciate others’ feelings, including mother’s
and group’s intentions to comfort
Coherence of mind:
● Reduce disruption caused by anger or self-loathing
Disorganized mental states:
● Appreciate role of abuse on affect states that lead
to binge eating
Note. AN ⫽ anorexia nervosa; BN ⫽ bulimia nervosa.
256
TASCA, RITCHIE, AND BALFOUR
impact on her mental state, yet she consistently downplayed the
effect of the abuse on her experiences and negative affect. The
anger, self-loathing, and disorganization associated with the abuse
most likely precipitated episodes of binge eating and purging.
The eating disorder treatment goals were to reduce her body
dissatisfaction and interrupt the binge eating and purging by setting a nonrestrictive and consistent meal plan and reducing the
affect dysregulation that preceded binge eating. The latter was
achieved by group psychotherapy. The goals for the group therapy
based on the attachment-oriented assessment were as follows: (a)
to encourage BP to more clearly identify her negative affect when
it occurs in order to help her downregulate her emotions; (b) to
experience safety in a group context to attenuate her neediness,
which in turn will reduce her threat appraisal, and to increase a
sense of belonging; (c) to encourage BP to develop coherence in
her narrative, especially with regard to early unmet attachment
needs and their relation to current acting out behaviors that she
might be substituting for unmet needs; (d) to help her develop
reflective functioning skills in order to gain some distance from
her negative affect that triggers impulsive behaviors (e.g., sexual
acting out, substance use, binge eating, and purging); and (e) to
help BP reduce her defensive denial about the impact of the sexual
abuse, so that it no longer has a disorganizing role in her mental
functioning. Table 3 summarizes goals for treatment of a patient
with attachment anxiety and an eating disorder like BP.
It took BP some time to disclose that she had sexual affairs with
friends’ boyfriends, largely because of her shame and fear that
other group members, all women, would reject her. This imagined
condemnation paralleled her extreme self-loathing. Eventually, she
did talk about her affairs, but immediately became distressed in
which she described herself very negatively. The therapist’s task at
that moment was to interrupt the self-denigration and consuming
negative affect, which interfered with narrative coherence, and to
encourage reflective functioning by having her thoughtfully consider her need to act out sexually given her early attachment
deprivation and experiences of sexual abuse.
BP: I would usually get drunk at these parties, and . . . Well,
there was one time when I slept with Sue’s boyfriend. Sue was my
best friend since high school. We did everything together.
Group Member: Why did you sleep with her boyfriend?
BP: I don’t know, I was stoned, I think, but I knew what was
happening . . . Sue won’t talk to me now, she hasn’t for months. I
miss her. I’m such a horrible person. You must think I’m awful.
What kind of a person would do such a thing . . .
Therapist: (interrupting). BP, it seems that when you get to this
point of trying to figure out what happened, you automatically beat
up on yourself, and then it becomes impossible for you to work on
understanding things. I know it’s hard, but I’m going to ask you to
put the self-criticism aside for a moment, to step back from those
feelings about yourself, and talk with us about what happened and
why. Do you think that you can try that?
BP: (crying, but makes eye contact). I’ll try.
The goal of the intervention was to encourage BP to distance
herself from her overwhelming feelings and to try to examine the
nature and reasons for her impulsive and self-destructive acts. The
distancing and reflection was necessary to downregulate her emotions so as to improve her affect regulation. It took several such
interactions and therapist interventions over a number of weeks in
which other group members were empathic and nonjudgmental in
order for BP to fully discuss her impulsive patterns without being
overwhelmed by shame.
At times, anxiously attached patients, like BP, believe they are
so incapable and so fearful of autonomy that they resist selfreflection. Simply encouraging the patient to reflect, as in the
example provided earlier, may not be sufficient. A therapist may
need to challenge the patient’s strategy of defensive denial of her
own strengths (Wallin, 2007). The following interaction, in which
BP described her anger at her mother and its effects on BP’s ability
to evaluate her mother’s current actions and intentions, illustrates
such a therapeutic challenge:
BP: I know my mother tries to listen to me, but I get so angry
that I can’t see that she’s trying. She eventually gives up and goes
to her room, which really pisses me off.
Therapist: How does it happen that your anger gets in the way
of seeing what your mother is feeling and intending?
BP: I don’t know (indicating an end to her exploring).
Therapist: Just because you don’t know right now doesn’t mean
you won’t be able to figure it out if you take some time. What I’m
asking is that you step back and think about it out loud so we can
figure this out.
BP’s experience of the group as being accepting was important
to reduce her fears of rejection and to encourage her to be reflective. By the end of treatment, she still felt great regret about her
sexual acting out and her anger, but she was able to talk about and
explore her past behavior without being overwhelmed by the
affect. For example, she was able to identify enormous needs to be
loved and wanted, both of which she never experienced in her
family of origin. She identified these needs as underlying her
sexual acting out and anger. This indicated improved coherence in
her narrative and reflective functioning. Concurrently, she gained
greater control over her behaviors, including binge eating; was
able to think through her decisions before acting; and was able to
take comfort in the support offered to her by the group.
As indicated, another goal of the therapy for BP was to help
reduce the disorganizing impact of the sexual abuse on her negative affect and states of mind. The current disorganization caused
by her grandfather’s abuse was illustrated in the following sequence:
BP: Christmas was always good in our family. I mean my father
often got drunk but he’d just sleep it off. Us kids always had a
great time, though. I remember one year when I was about 7 or 8
we got this table hockey game and . . . we, ah . . . Sorry, I lost
track.
Therapist: What just happened there when you lost track?
BP: I don’t know.
Therapist: It sounded like a nice memory. You were talking
about Christmas and a table hockey game.
BP: Oh, my grandfather bought us that game.
Therapist: Thinking about your grandfather really disrupted
you.
BP: I guess It did (crying).
Therapist: I’m guessing that you get disrupted by memories of
your grandfather more often than you realize. It seemed to happen
automatically.
BP: Yah. I never really thought of it that way.
Through interactions like this, BP was able to recognize the
ongoing disorganizing effects of the sexual abuse and subsequent
increases in her urges to act out sexually, use substances, and to
SPECIAL SECTION: IMPLICATIONS OF ATTACHMENT THEORY
binge and purge. By the end of treatment, she was more open to
discussing the abuse, her family’s handling of the abuse, and her
nagging fear that somehow she was to blame. These discussions
were less disorganizing because she developed a more coherent
narrative of the role that the abuse played in her development and
current state of mind.
Attachment and the Therapeutic Relationship
The transference and countertransference experiences with patients who have an eating disorder vary considerably, but one can
broadly describe typical interactions with the attachment-avoidant
and anxious patient that may guide therapists. JK, for example,
despite her anorexia, was high functioning in some areas. In the
group therapy, JK was helpful to others by providing advice and
comments, and other group members looked to her for leadership.
Her advice, though helpful, was not emotionally connected, and
therefore lacked a fully empathic quality. Both patients and therapists described her as “intimidating” and she often scowled or
brooded if challenged or confronted. She initially dismissed, for
example, her conflicts with her father and the impact that this had
on her mood. Group members avoided confronting her partly
because of her underlying anger, and by doing so the group
inadvertently colluded with JK’s pseudo leadership role. Therapists also felt the countertransference pressure to avoid confronting
JK. However, the therapists also understood JK’s need to control
her affect, and that early confrontations or demands for her to
explore painful emotions would likely have resulted in extreme
discomfort and dropping out of therapy. The group therapy interaction described in the following text occurred 8 weeks into a
group-based day hospital program, and illustrates how JK’s
avoidant interpersonal style and her attempts to downregulate her
emotions affected her relationships in the group.
Group Member: I was afraid of telling the group about my
symptoms because I thought they’d be disappointed in me.
Therapist: Who in particular did you think would be disappointed?
Group Member: Well, (pause) I thought JK would disapprove
(Group Member winces).
JK: (annoyed) What? How can you say that? I’m always there
for you.
Therapist: (to Group Member) Why JK?
Group Member: Well she’s like the leader among us (patients).
I look up to her and she has such high standards.
Therapist: (to Group Member) Do you feel close to JK? Emotionally connected?
Group Member: (pauses) I look up to her. I know she cares, but
she’s sometimes intimidating and that makes it hard to really feel
close, even though I’d like to be closer.
JK: (crying) I don’t know what to do. I don’t think I belong here.
I should leave.
Therapist: (to JK) Whenever we get close to your emotions in
the group you want to leave—it’s a way of protecting yourself. But
(Group Member) is saying something that you’ve been concerned
about all along—that you’re not as emotionally close to people as
you’d like to be. She’d also like to be closer to you. So it’s
important now for you to let yourself be vulnerable in the group
even though it’s scary. That would be a different way of dealing
with your feelings instead of getting angry and leaving.
257
JK: I know. I do the same thing with my father. I blow up and
leave whenever things get hard, and nothing gets resolved.
In contrast, for a patient with an eating disorder like BP, whose
attachment mental states were anxious and preoccupied and whose
affect was more volatile, the group therapy relationships took on a
more emotionally charged quality. For example, in a previous
group therapy session, BP began talking about her rage toward her
mother. The therapist anticipated another cycle of anger followed
by self-loathing. Possibly to protect himself from BP’s difficult
and intense emotions, the group therapist made a therapeutic error
by shifting the discussion to another patient. BP fell silent for the
remainder of the group session. Realizing his mistake, the therapist
revisited the events of the last group in the following session with
BP. His intent was to repair the rupture in the therapeutic alliance,
and to use the event to help BP understand her tendency to end
relationships for fear of being rejected by others.
Therapist: I want to go back to what happened last week when
I interrupted you and then you became really quiet.
BP: I knew you were going to talk about last session. But I’m so
angry. I don’t think that I can talk about it (starts crying).
Therapist: Yah, I can see that. I can imagine that you experienced it as another example of someone in authority letting you
down, disregarding your feelings, or rejecting you. I was concerned that you would cycle out of control with your anger and
guilt, but I see now that what you really needed was for me to listen
and be there with you.
BP: (softer) Yah.
Therapist: Does it remind you of other situations in your life?
BP: Yah, well. My mother would always be in her own world,
she still is. I could never talk to her. I was always on my own even
when those things happened to me. I get so angry when I think
about it.
Later in the session, the therapist returned to the alliance rupture.
Therapist: Are you still upset about last week?
BP: No. I can see that you meant well and I appreciate that you
want to work it out.
Therapist: Yah. My sense though, was that you had written off
our relationship.
BP: I know I tend to do that. But I didn’t really do that this time.
I came back knowing that you would bring it up.
Therapist: Yes you did. Why did you come back?
BP: I’m not sure. I just can’t keep ending relationships because
I get angry or because I expect the other person will leave me. I
have to push through the anger. I can’t be alone and angry all the
time, that’s usually when I end up binging.
Conclusion
Research on the treatment of eating disorders suggests that those
with attachment insecurities most likely benefit the least from
current symptom-focused treatment approaches. In this practice
review, we argue that the treatment of eating disorders could be
improved with a dual focus on eating disorder symptoms and on
attachment functioning. We suggest an approach by which clinicians evaluate attachment categories (e.g., anxious, avoidant).
Within those categories, clinicians can assess domains of attachment functioning, including interpersonal style, affect regulation,
coherence of mind, and reflective functioning, and also assess
TASCA, RITCHIE, AND BALFOUR
258
disorganized mental states related to loss or trauma. Two cases
were presented to illustrate the psychotherapy of individuals with
an eating disorder that is informed by attachment theory. Table 3
provides a summary of the therapeutic foci that address eating
disorder and attachment-related goals for treatment of these two
cases. These therapeutic foci provide a template by which differential treatment approaches can be applied for the eating disorders
based 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. Tailoring treatments to target attachment
functioning for patients with an eating disorder will most likely
result in better symptom outcomes and improved long-term interpersonal functioning, emotion regulation, and mental states.
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Received October 25, 2010
Revision received November 11, 2010
Accepted November 12, 2010 䡲