BRIEF REPORT

Attachment theory, metacognitivefunctions and the therapeuticrelationship in eating disorders

C. ArdoviniSocietà Italiana per lo Studio dei Disturbi del Comportamento Alimentare (SIS-DCA) Società Italiana di Terapia Cognitivo-Comportamentale (SITCC)

ABSTRACT. J. Bowlby’s attachment theory is used to explore a fundamental motivationalforce in human behaviour, namely the search for physical and emotional protective intimacyaccording to an integrated viewpoint remote from Freud’s drive-based approach. This theoryhas received contributions from ethology, the neurosciences, psychoanalysis, cognitive psy-chology and evolutionary epistemology. Attachment patterns or styles express both the men-tal and behavioural strategies adopted by individuals to cope with their attachment needs,and their relational history in this area. Experiences of adequate quality promote metacogni-tive functions, namely a set of mental processes whose role is to protect the individual frompsychopathological suffering and construct and articulate a sense of self. Attachment theoryand metacognition are the underlying assumptions of reflections on the dynamics markingthe development of sometimes very difficult relationships between therapists and eating dis-order (ED) patients, who are being increasingly classed as “severe patients” on account oftheir interpersonal characteristics. (Eating Weight Disord. 7: 328-331, 2002). ©2002, Editrice Kurtis

Attachment behaviour is dynamicallycontrolled by an innate interpersonal sys-tem (1) whose function is to motivate thesearch for protective intimacy, protectionand comfort in situations of personal vul-nerability from figures constructed asauthoritative. The quality and characteris-tics of the interaction between child andcaregiver condition the construction of cog-nitive-affective representations of growingcomplexity in relation to his development.These are defined as internal working mod-els, whose contents refer to perception ofthe self and of the other in their relationshipand characterise the attachment style of theindividual. In other terms, they direct thechoice of the behavioural modalities experi-enced as being most effective in seekingand maintaining intimacy with the caregiv-er. In a very young child (12-18 months),patterns are identified by the “strange situ-ation” procedure whereby a child isexposed to brief episodes of separationfrom the caregiver, alternating withmoments of reunion (2). The way in whichhe reacts expresses the quality of theattachment with this figure, usually the

mother. Children, of course, establish simi-lar relationships marked by differentdegrees of quality with more than one per-son. Representations of the figures involvedare thus mentally ranked according to a hier-archy in which the mother is usually pre-emi-nent.

Application of the “strange situation” tomany samples from the general population indifferent countries and cultures has led to theidentification of four attachment patterns:

- the most common pattern among low-riskchildren is called “secure” and indicatedwith the letter B. When separated fromthe mother, the child cries and protestsvigorously. When the mother returns, heseeks intimacy and once he is comforted,he returns to his exploratory activities;

- the “avoidant” pattern (letter A), ex-presses an apparently indifferent behav-iour on the part of the child when reu-nited with his mother, as if he does notperceive her return.

There are no manifestations of seekingintimacy and being comforted. His attentionremains focused on his play as it was whenhe was separated from her:

Key words:Attachment theory,attachment patterns,metacognition, therapeuticrelationships, self.Correspondence to:Dott. Cristiano Ardovini, Via R.R. Pereira 8, 00136 Roma, Italy.Received: April 10, 2001Accepted: November 13,2001

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- the “resistant-ambivalent” pattern (letterC) is observed in only 10% of low-riskchildren. At the moment of reunion, thechild seeks intimacy, but seems unableto enjoy the comfort he receives as if hewere resisting the mother’s offer of con-solation. Besides, he often showsintense anger, for instance by turninghis face away from his mother when shepicks him up in her arms, even thoughhe does go on seeking and demandingcomfort:

- the “disoriented-disorganised” pattern(letter D). Here the reunion is charac-terised by behaviours that are not solelyaimed at searching for intimacy. It is asif the child has not succeeded in organ-ising a single strategy when his attach-ment needs are activated.

There are various ways of identifyingattachment patterns in later life. In theadult, a semi-structured interview calledthe “adult attachment interview” allows anaccurate and thorough exploration of aperson’s attachment experiences (3).Decoding takes into account not only thecontents, but also and above all the formalcoherence of narration. Widespreadadministration of this interview has result-ed in the description of four “mental statesrelated to attachment”. These are signifi-cantly correlated to children’s patterns anddefined as “free-autonomous” (B pattern),“preoccupied-enmeshed” (C pattern), “dis-missing the attachment” (A pattern), and“unresolved” (D pattern).

The internal working models and themental states concerning attachment, arepresentational expression of the corre-sponding interpersonal experiences, areindicated by several investigators as signifi-cant elements in shaping and directing per-sonality development. The difficultiesencountered during the complex process ofsocial adjustment, poor flexibility andresilience in facing life’s painful events, thepossibility of building a sense of self that iscoherent and integrated, of producing afluid and coherent narration, ultimatelypsychopathological suffering itself, seem topoint to the attachment pattern as animportant aetiopathogenic factor (4). Theprotective role of the B pattern in facingpsychopathological risks is related to itsfunction during development of themetacognitive capabilities (5). Metaco-gnition means treatment of one’s mental

contents as “objects” on which to reflect, orin other words “thinking about one’s think-ing”. Distinct skills contribute to its charac-terisation, such as the ability to reflect onone’s mental states, elaborating a theory ofthe other’s mind, decentralising, and thesense of mastery and personal efficacy.Construction of an integrated and coherentsense of self seems to derive from thesefunctions which, albeit working correctly,are hampered if not made downrightimpossible by a child’s repeated failure toget a sensitive response and empathisewith the caregiver. The attachment theorycan thus be used to build an explanatorybridge between the quality of past and pre-sent relations and metacognition on theone hand, and mental health on the other.

The interpretation proposed sheds lighton the mysteries of disorders that predis-pose to inadequate eating patterns andcondition a patient’s relational approachduring treatment (6-8). The role of the earlyattachment patterns and their internalworking models in the development of EDshas been examined in several treatises.Some authors postulate a link betweeninsecure attachments in general and EDs asa class(9-11), others propose links betweenspecific attachment patterns/internal work-ing models and specific types of ED (12-14).There is no conclusive evidence for thissecond view.

Links of various kinds between earlyattachment experiences and the develop-mental psychopathology of EDs have beensuggested, whereas the influence of attach-ment patterns in the relationship createdwhen they are treated has not beenexplored. To do so, one must pay particularheed to changes in the interpersonal atti-tudes of patients and therapists within theirrelationship, proceed beyond specificsymptoms towards the representations ofself and others conveyed by the internalworking models as evoked by the care-seeking/caregiving interactions betweenpatient and therapist, and move from a cat-egorical approach to psychopathology anda dimensional approach.

It is the difficult albeit necessary task ofcontrolled research to identify the specificfactors for the choice of a given develop-mental pathway stemming from earlyattachment experiences. It is the task ofpsychotherapy to describe how knowledgeof early attachment patterns can guide the

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clinician in handling a patient’s problem.Fulfilment of this task with regard to EDs isthe aim of the present paper.

Internal working models focus on anindividual’s expectations vis-á-vis the rela-tional side of the request for treatment andmay explain his distrust of treatment itself,especially psychotherapy, which requiresperception of his vulnerability and showingit to the person from whom he is seekinghelp and support (15). The initial relation-ship is mainly driven by attachment, adimension burdened by more or less pro-found “wounds” as in all psychopathologi-cal situations. The meaning of unwilling-ness shown during the initial interviews,and more often in the later stages as well,may well depend on the patient’s attach-ment style.

In the avoidant individual, therefore, reit-erated refusal of his request for help hasmade him defensive with regard to hisattachment needs. Their inhibition, often bydiscounting them and making a show ofself-sufficiency, enables him to avoid newrefusals and reduce the risk that the othermay become irritated and leave forever.Showing confidence in someone meansexposing oneself to the risk of beinginjured and feeling unilaterally dependentwithin a relationship with an unattainableperson. It is of the utmost importance thatthe therapist show respect for the tendencyof patients of this kind to discount theimportance of relationships.

Constructing a therapeutic alliance is atime-consuming and complex process longdominated by the fear of betrayal and ofsolitude. Expression of the patient’s suffer-ing can only be elicited by repeated demon-strations of empathetic responsiveness andthe therapist’s acceptance of the attach-ment needs that have made him avoidant.

The resistant-ambivalent patient’s attach-ment needs, on the other hand, havereceived contradictory and unpredictableresponses. Moments of comforting physicaland emotional intimacy have alternatedwith moments of despairing aloneness andlack of attunement, while the attachmentfigure’s caring attitudes were sometimesmarked by relational control, as if caringwere tantamount to conditioning or domi-nation. Drawing close to the other is thusaccompanied by the expectation of re-expe-riencing the anxiety of unpredictable avail-ability, the fear that allowing oneself to ask

for and obtain care may mean giving upone’s identity and independence. Buildingup a sound therapeutic alliance with thesepatients requires demonstration of a readi-ness to accept their attachment needs with-in well-defined bounds, along with con-veyance of the relational message that ask-ing for and receiving care does not entailcontrol, nor the surrender of one’s freedomof expression and assertiveness.

The situation of the disoriented-disorgan-ised patient is even more complex. His pat-tern has its roots in traumatic attachmentexperiences, such as psychological, physi-cal or sexual violence within the family, or arelationship with a caregiver with psychi-atric disorders or unresolved loss (4).

Searching for and maintaining intimacytriggers unbearable anxiety and fears thatmake it difficult to satisfy his attachmentneeds. A connection has been shownbetween disoriented/disorganized attach-ment and severe psychopathologic problems,such as personality disorders, dissociation ofthe state of consciousness and EDs (16).

This pattern can be recognised in EDpatients who have a psychiatric comorbidi-ty and whose clinical presentation is oftencomplicated by multi-impulsivity. Buildingup an adequate therapeutic relationship inthese cases constitutes a formidable obsta-cle along the road to recovery. An apparentdistance is formed and ultimately breaks upthe relationship. Joint management is thusan increasingly frequent feature of clinicalsettings in which diversified relational con-texts of care/treatment enable attachmentneeds to be met by several figures. Resortto an integrated and multidisciplinaryapproach is widely recommended and maybe partly motivated by the need to over-come the profound difficulties encounteredin the building up of a sound therapeuticalliance. As mentioned earlier, this seemsparticularly true for patients whose attach-ment history is indicative of a disoriented/disorganised attachment pattern, sincetheir request for care is imbued with terri-fying anxiety. The integrated approach,however, will only be really effective if theoperators can maintain a close and mutualcontact and build up genuinely cooperativerelationships. It also exposes the patient tothe risk of iatrogenic interventions thatmay complicate an already far from smoothcourse of treatment.

Consideration of attachment patterns thus

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requires the devotion of special attention tothe patient’s interpersonal dimension of dis-tress, full respect for his suffering and fullawareness of the functional value of his dis-turbed behaviour. It means creating newconditions in which a relationship can devel-op, a sort of corrective emotional experiencethat sets out to remedy the deficiencies in hismetacognitive development. It means creat-ing the relational conditions for expandingawareness, for integrating the aspects of theself that have remained at a distance or havebeen severed/split. It means embarking onthe construction of a coherent self, of asmooth and coherent narration that Janetcalled “personal synthesis” (17).

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