Exploring Patterns of Attachment Narratives in Families with Anorexia

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Exploring Patterns of Attachment Narratives in
Families with Anorexia

• Dr.Rudi Dallos
• Clinical Teaching Unit
• HSW
• University of Plymouth

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CLINICAL CONTEXT and BACKGROUND

• ANOREXIA
• CONTEXT
• Specialist clinical services for young people
  with anorexia Kent and Somerset, CAHMS
  community based services in Somerset
• CLINICAL OVERVIEW
• High rate of mortality
• 90 female condition
• Low rate of success, high risk of relapse
• Young people hard to engage in therapy
• Families hard to engage in therapy

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CLINICAL and THEORETICAL BACKROUND

• Individual therapy CAT, CBT, PCT, Psychodynamic
• Bruch anorexia as protest against the mother,
  flight from sexuality
• Slade need for control, perfectionism
• Family Therapy
• Structural Therapies Minuchin conflict
  avoiding, enmeshed, confused hierarchies
• Systemic - Palazzoli et al denial of conflict,
  child triangulated in secret conflicts between
  parents
• Families very hard to engage in clinical work and
  conversation tends to shut down regarding
  relationships, feelings and possible impact of
  these on the anorexia

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ATTACHMENT THEORY

• ATACHMENT STYLES
• Secure
• Avoidant
• Anxious/ambivalent
• Processes in Families with anorexia appear to fit
  and Avoidant pattern
• Shut down of feelings
• Avoidance of conflict
• Little evidence of comfort
• Attachment Theory and Narratives the AAI
• Styles reflected in patterns of discourse
• Narrative as skill coherence, reflective
  functioning
• Secure base fosters narrative skills
• Patterns across the generations actions and
  narrative styles ?

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RESEARCH QUESTIONS AREAS OF EXPLORATION

• GENERAL
• Exploration of attachment narratives in families
  with a member with anorexia
• Exploration of trans-generational patterns
• Diversity of attachments in families -
  variability of attachment narrative styles
  amongst different family members
• SPECIFIC
• Accounts emphasising specific lack of experiences
  of comforting
• Connections between narratives regarding comfort
  generally and food as comfort

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RESEARCH DESIGN and METHOD

• Qualitative study
• Case Study 4 families
• Young person with anorexia, sibling, mother and
  father
• Interviews - 4 individual interviews
• Observation family interview, video taped

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SAMPLE

• VERY HARD TO RECRUIT THE SAMPLE !!!
• Four Families previously in NHS services
• Convenience sampling
• Recruited through therapy contacts Taunton and
  Bristol
• All have experienced individual and family
  therapy
• Young Person who has been diagnosed with anorexia
• Young Person ( 16 19 years) now in recovery
  no longer dangerously low weight, or actively
  pre-occupied with self starvation, BMI 18
• Sibling - two younger, two older, two male, two
  female, no significant experience of eating
  problems
• Parents two intact families, three divorced
• Male adult step-father in one family
• Supporting Sample
• Five families parents only interviewed
• Four siblings of young people with bulimia
  interviewed
• Clinical practice based research with 20
  families

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INTERVIEWS

• Semi- structured
• Modified version of the AAI ( Adult Attachment
  Interview)
• Family Interview
• Additional Questions
• Patterns of comforting
• Comforting and food
• Memories of mealtimes
• Corrective and Replicative scripts especially
  regarding food and comforting

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THE ADULT ATTACHMENT INTERVIEW

• Family Context
• Nature of relationships attachment figures
• Attachment perceptions and memories 5
  adjectives/phrases
• Comfort danger, threat, distress
• Loss and separation
• Abuse, abandonment
• Integration
• Replicative and Corrective scripts
• Increasing level of anxiety deliberately
  generated by the interview
• Could be used as a course of therapy one or
  more sessions per area?

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ANALYSIS

• Interprerative analysis of beliefs and
  narratives - drawing on IPA ( Interprerative
  Phenomenological Analysis
• Discourse Analysis drawing on discourse markers
  use in the AAI overall attachment styles and
  specific use of different discourse patterns
• Observational Analysis of the family video
  interview drawing on systemic analysis and
  attachment theory

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PRELIMINARY RESULTS

• Consistent pattern across the four families of
  negative attachment experiences across the
  generations typically avoidant
• Accounts feature lack of comfort, self
  reliance, reversal of caring ( child looking
  after parents emotional needs)
• Some diversity in the families parents in some
  cases hold different attachment styles (
  avoidant pre-occupied) and siblings may hold
  different patterns
• Consistent lack of comforting reported across the
  generations
• Discourse features consistently show insecure
  patterns across the generations, in relation to
  comfort, fear, threat, dealing with loss
• Food seen as aversive and not associated with
  comfort or pleasure - consistent across all of
  the families
• Evidence of corrective scripts across the
  families attempts to make things better in the
  current family
• SUGGESTION of DEFECITS in NARRATIVE SKILLS -
  e.g. reflective functioning, coherence and
  integration

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DISCOURSE MARKERS in attachment narratives

• USE of MEMORY SYSTEMS
• Cognitive and semantic
• Emotional details
• Visual memories
• COHERENCE
• Causal and Temporal events in an ordered form
  and connected causally
• Consistency between memory systems, especially
  between semantic descriptions and episodes
• PROCESSING of INFORMATION
• Transforming shaping information/memories about
  events
• Fluency/dysfluency breakdown of narrative
  rambling, inconclusive
• Fit between non-verbal features and semantic
  laughter, hesitation etc.
• REFLECTION
• Ideas about others internal states and feelings
• Ideas about own internal states and feelings
• Awareness of inconsistencies in own thinking and
  feelings

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Discourse markers AVOIDANT

• Omission of self from sentences about self,
  especially Omission of all people from statement
• Use of distancing pronouns instead of personal
  pronouns
• Omission of all people from statement
• Minimizing of negative experiences
• Nominalisation of affect
• Distancing phrases, cut-off phrases
• Telegraphic speech, lack of details
• Stilted, literary style of speech
• Normalisation of vulnerable self
• Hypothetical phrasing
• If/then, when/then contingencies
• Gratuitous denial of negative feelings.

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Discourse markers PRE-OCCUPIED

• Confusion of person
• Confusion of time (oscillating between past and
  present)
• Confusing manner of speech
• Vagueness of meaning through meaningless or
  qualifying phrases
• Intrusion of irrelevant detail
• Episodes told in the form of a dialogue
• Passive semantic thought does not come to a
  conclusion/ point
• Stream of consciousness flow of speech, without
  focussed direction.

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Claire and her Family
Weekend partner, when Margaret a child Margarets
mother depressed?
Alvin 59
Margaret 56
Clair anorexia since 15 Margaret affair 10
years ago Alvin affair 13 years ago Margarets
mother suffered in silence through fathers
long-term affair Alvin and Margaret quarrels for
years Alvin demands sex Margaret not
interested Margaret threatening to leave Alvin
Claire 17
Paul 32
Darren 28
Mark 34
AT HOME Margaret, Alvin, Clair, Paul ( moved
back for a while) Clair studying psychology
wants to be a clinical psychologist, like
her female therapist
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CLAIRE

• Int ..can you describe your family in terms of
  relationships ?
• Claire Its very false, its very strange. I mean
  its changed a lot. When I was younger it was
  just awful all the time, I dont like anger now,
  its like, arguing non stop. It was horrible I
  would do anything to stop them arguing and anger
  is like fear. I dont like anger now, its like
  an emotion that cant be controlled and that
  scares me....But recently everyones been really
  trying but it still seems, it seems really false
  to me..
• The only thing I ever hear them talking about is
  me and if I didnt have this anorexia its kind
  of like, would everything fall apart, at least
  its keeping them talking. And they wont argue
  while Ive got this because it might make me
  worse. So um...thats kind of bought, sort of
  like, Im not in control as such but Ive got
  more control over the situation that way.
• Int So if you were upset or distressed or
  frightened when you were young, who would you go
  to?
• Claire Nobody. I wouldnt go to anybody. The
  only time I ever did was once when Mum was at
  work and I had to sleep in my brothers room. I
  cant remember why, and there was a picture of me
  and her when we were little, cuddling, and I was
  only young and I was looking at this picture and
  I was crying so much because I thought because
  theyre older than most parents that she was
  going to die really soon and I went down to Dad
  and he was like Dont be stupid and go back to
  bed, and I had to go back to bed. And after that
  I didnt bother going to him. I would just bottle
  it all up and just not bother

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PAUL Claires brother

• Int .example of a time your mum cared ?
• Paul My memory as child isnt that good um,
  generally, um..I cant remember hardly anything,
  (slight expelling of breath) good or bad, umI
  know we used to get a lot of Christmas presents,
  and I remember at the time thinking this is
  ridiculous, she neednt give us this many
  presents so,. But you see, I dont..because
  there were three of us , we werent generally
  spoilt, but we would be spoilt at Christmas, so I
  remember that. It wasnt so much that there were
  so many presents, it was just the fact that she
  wanted to give us that many. Not the presents
  themselves.
• Int Who would you turn to if you were upset, or
  hurt?
• Paul As a child? Um I dont really remember
  being particularly hurt, upset or frightened, to
  be honest. I think I, I was, I was a fairly
  self-contained child, you know, I didnt, I had
  friends but I generally played on my own. Umin
  some respects probably a loner, but not
  ..consciously so. Just quite happy with my own
  company and my own, living in my own head.
  Umyeh, see Ito be honest I cant really
  remember being.I, I tell a lie, I supposes there
  were a few occasions at primary school where I
  was worried about tests or doing talks or things
  like that. I remember that. But I dont remember
  doing anything in particular, I remember my
  parents were there, but I cant remember exactly
  what I did. So,
• Int So if you fell over.what would you do?
• Paul UmId probably show it to my parents ,
  well probably my mum, because shed be the one
  most likely to be around, and shed say dont
  worry about it and push you back out again.
  Umyeh that was her way, that was the way she was
  brought up. If we were ever under the weather ,
  wed have to be at deaths door before wed be
  kept back from school. Um..er at the time I
  didnt blame her for that and I dont now either,
  I think if, if you, you have to be careful to
  strike a balance between being overly protective
  and also being.. No youll be fine, get on with
  it. I certainly didnt feel I was getting
  rejected in there. But that was her way of
  dealing with it. Um.

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MARGARET Claires mother

• Int I just wonder if you could give a memory,
  or an example of when your mum was
  uncommunicative?
• Margaret I think she had a lot on her mindI
  believe she felt a bit like I felt in my
  relationship with my Dad because she tried to
  commit suicide when I was, I think was only six
  months old. And my mum told us about it because
  she made my Dad go but my dad went back and said
  that he loved both of them but he stayed with my
  Mam and the children, but he still continued to
  see this other woman. And I think she just had a
  lot on her mind.
• Int ..You said you think your mother saw you as
  the bad one
• Margaret Well, it was always a jokethe
  scruffiest kids and they were always talking
  about me and I had nits and things cause I had
  ..(pause sounding tearful) . It was a
  joke(crying)I remember going to the
  hairdressers and it was so embarrassing because I
  was, I dont know, I must have been about 13 or
  14 and they washed my hair and then somebody came
  across and after theyd washed it they said that
  they couldnt do anything and that was so
  humiliating and I never told my mum.
• Int If you were distressed or hurt or afraid how
  was it dealt with?
• Margaret .Id probably try to deal with it
  myself I think because I dont like um
  attention, I dont like people to feel sorry for
  me or anything like that
• Int And as a child, can you remember who you
  would go to or what you would do?
• Margaret I dont think there was anybody I went
  to, no.

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ALVIN Claires Dad

• Int So, it was a distant relationship?
• Alvin It wasnt an affectionate relationship. I
  cant remember the touchy-feely side of my mum.
  My father was like that. He loved to put his arm
  around you and tickle you. In fact, I remember
  he used to chase me with a wet flannel. Um....I
  just cant remember her cuddling me. I remember
  me cuddling her basically.
• Int if you were particularly distressed or
  afraid how was it dealt with?
• Alvin I dont remember being afraid..I was
  once ill. Id eaten something from a mussel which
  poisoned me. I remember we had this old grate
  fire and if I got chicken pox shed bring the bed
  down and put us all in it so wed all get it,
  which seemed a crazy idea but it is probably the
  best in the long run
• Family relationships current family
• Alvin We used to argue a lot (he and his
  wife)...And um.Claire used to come down
  sometimes when we were arguing in the kitchen,
  she was in bed. And she used to come down and say
  I wish you two would stop. Youre doing my head
  in ..Which has come back to haunt us really.