See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/226791121

Attachment Style and Family Functioning as Discriminating Factors in Eating

Disorders

Article in Contemporary Family Therapy · December 2002

DOI: 10.1023/A:1021273129664

CITATIONS READS
97 2,101

4 authors:

Yael Latzer Zipora Hochdorf

University of Haifa Rambam Medical Center
140 PUBLICATIONS 2,843 CITATIONS 10 PUBLICATIONS 272 CITATIONS

SEE PROFILE SEE PROFILE

Eytan Bachar Laura Canetti

Hebrew University of Jerusalem Hadassah Medical Center
81 PUBLICATIONS 1,826 CITATIONS 50 PUBLICATIONS 2,880 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Eating disorders View project

Psychology of Immigration View project

All content following this page was uploaded by Eytan Bachar on 31 May 2017.

The user has requested enhancement of the downloaded file.

ATTACHMENT STYLE AND FAMILY
FUNCTIONING AS DISCRIMINATING
FACTORS IN EATING DISORDERS
Yael Latzer
Zipora Hochdorf
Eitan Bachar
Laura Canetti

ABSTRACT: This study sought to examine the extent to which family

environment and attachment styles are concurrently related to eating
disorders. The Adult Attachment Scale and the Family Environment
Scale were administered to 25 anorexic and 33 bulimic female patients
at intake in an eating disorder clinic, and 37 age-matched female con-
trols. Eating disorder patients were found to be less secure, more avoid-
ant, and more anxious than controls. The families of eating disorder
patients were found to be less cohesive, expressive, and encouraging
of personal growth than were controls. Low encouragement of personal
growth and uncertain attachment styles may be manifestations of fam-
ily difficulties in supporting the child during the process of separation
individuation, and exploration of the outside world.
KEY WORDS: attachment styles; family environment; eating disorders.

Yael Latzer, DSc, is the Director of the Eating Disorders Clinic, Psychiatric Division,
Rambam Medical Center, Haifa, Israel, and a lecturer in the School of Social Work,
University of Haifa, Haifa, Israel. Zipora Hochdorf, PhD, is on the Faculty of Education,
University of Haifa, Haifa, Israel. Eitan Bachar, PhD, is Chief Psychologist at the Depart-
ment of Psychiatry, Hadassah University Medical Center, Jerusalem, Israel. Laura
Canetti, MA, is a researcher and clinician at the Department of Psychiatry and Human
Nutrition and Metabolism, Hadassah University Medical Center, Jerusalem, Israel.
Address reprint requests to Yael Latzer, DSc, Director Eating Disorders Clinic, Division
of Psychiatry, Rambam Medical Center P.O. Box 9602, Haifa, 31096, Israel. (latzer@
netvision.net.il).
We would like to acknowledge the assistance of Galia Golan, research assistant.

Contemporary Family Therapy 24(4), December 2002  2002 Human Sciences Press, Inc. 581
582

CONTEMPORARY FAMILY THERAPY

Eating Disorders (EDs) have received considerable attention in

both the professional and popular literature during the last three de-
cades. This is due, in part, to the increasing prevalence of EDs in
the Western world and the high mortality rate associated with the
syndrome (Deter, Herzog, & Manz, 1994; Eckert, Halmi, Marchi,
Grove, & Crosby, 1995; Herzog et al., 2000; Hobbs & Johnson, 1996;
Neumarker, 1997). EDs are thought to develop as the result of interac-
tions between a number of variables, including biological, cultural,
personality, and family factors (Beumont, Russell, & Touyz, 1993; Gar-
finkel & Garner, 1982).
The issue of family factors has been the focus of much research on
ED. Specific attention has been given to the function of the pathological
family system in the etiology and maintenance of anorexia nervosa (AN)
and bulimia nervosa (BN) (Bruch, 1973; Crisp, Harding, & McGuiness,
1974; Dare, Le Grange, Eisler, & Rutheford, 1994; Humphrey, 1986,
1988; Kog, Vandereycken, & Vertommen 1985a, 1985b; Minuchin,
Baker, Rosman, Milman, & Todd, 1975; Minuchin, Rosman, & Baker,
1978; North, Giwers, & Byram, 1995; Selvini-Pallazzoli, 1974). Studies
examining the modes of interaction within such families have concen-
trated on variables such as social adjustment of the family, family
structure, family roles, communication deviation, and styles of coping
with manifest and latent conflicts (Dare, Eisler, Russel, & Szmukler,
1990; Kagan & Squires, 1985; Kog, et al., 1985a, 1985b; Kog & Vander-
eycken, 1989; Latzer, 1993; Latzer & Gaber, 1998; Minuchin, Ros-
man, & Baker, 1978; Selvini-Palazzoli, 1974; Szmukler, Eisler, Rus-
sel, & Dare, 1985).
Several studies have focused on the role of the family environment
in relation to anorexic and bulimic patients using different rating scales
and found that certain family patterns are associated with ED (Hum-
phrey, 1986, 1988; Strober, 1981; Strober & Humphrey 1987). The
Family Environment Scale (FES) (Moos & Moos, 1976) has been used by
a number of investigators in this context, however, the results obtained
using this scale have been partly inconsistent (Felker & Stivers, 1994;
Hodges, Cochrane, & Brewerton, 1998; Johnson & Flach, 1985; Leon
et al., 1985; Lyon et al., 1997; Ordman & Kirschenbaum, 1986; Strober,
1981; Thineneman & Steiner, 1993; Stern et al., 1997).
This lack of consistency may be due to the focus on different ED
populations and different subscales of the FES. Another explanation
for the nonexclusive and diverse results is that family environment
may be associated more with secondary psychopathology than with ED
symptoms per se. This suggestion is supported by research showing
 583

YAEL LATZER, ZIPORA HOCHDORF, EITAN BACHAR, AND LAURA CANETTI

that family environment variables make independent contributions to

those ED subscales that are more generally reflective of psychological
and social adjustment (Brookings & Wilson, 1994; Head & Williamson,
1990; Thienmann & Steiner, 1993).
Family environment that is unable to provide a sense of security,
availability, and attunement to the child’s needs has been identified
by attachment theorists as contributing to the pathologization of depen-
dency or detachment that characterizes a number of mental disorders
(Bowlby, 1988) and in ED particularly (Bachar, 1998). Researchers of
attachment processes have emphasized that individual differences in
adolescent and adult attachment styles may be related to psychological
difficulties and adjustment problems (Ainsworth, 1989; Collins & Read,
1990; Kobak & Cole, 1994; Mikulincer & Florian, 1995; Brennan &
Shaver, 1995; Hochdorf, 1999; Mikulincer & Florian, 1995, 1998; Miku-
lincer & Horesh, 1999; Mikulincer & Nachshon, 1991; Mikulincer &
Orbach, 1995). Several researchers have shown that insecure attach-
ment experiences are associated to difficulties with separation and
individuation from the attachment figure during adolescence (Rice,
Fitzgerald, Whaley, & Gibbs, 1995).
Empirical work specifically examining anorexia and bulimia has
linked these disorders to a disrupted attachment behavioral system.
Consistent findings have been obtained using a number of different
instruments (Bartholemew & Horwitz, 1991). examining attachment
styles. The results of a number of recent studies have indicated that
ED patients are significantly more anxious and evidence less secure
attachment than their normal controls (Armstrong & Roth, 1989;
Chassler, 1997; Cole-Detke & Kobak, 1996; Evans & Wertheim, 1997;
Friedberg & Lyddon, 1996; Kenny & Hart, 1992) Other researchers
have shown that the perpetuation of insecure attachments in adult
relationships is related to ED (Armstrong & Roth, 1989; Friedlander &
Siegel, 1990; Heesacker & Neimeyer, 1990; Humphrey, 1987; Kenny &
Hart, 1992).
In sum, research findings suggest an association between insecure
attachment and ED, as well as an association between family environ-
ment and ED. Research has also revealed a relationship between family
environment and attachment styles (Mazor, 1994; Hochdorf, 1999).
However, to date, the concomitant interrelationships among attach-
ment styles, ED, and family environment have not yet been examined.
The present study sought to examine this issue. On the basis of previous
research, it was hypothesized that; (1) The family environment of ED
individuals would evidence lower levels of cohesiveness, expressive-
584

CONTEMPORARY FAMILY THERAPY

ness, encouragement of personal growth, and maintenance than fami-

lies of normal controls. (2) The attachment styles of individuals with
ED would be characterized as less secure, more avoidant, and more
anxious than normal controls. (3) An interaction would be found be-
tween the family environment factors and insecure attachment styles
among ED patients.

METHOD

Participants
The participants included 25 female AN patients (mean age 22.3 ±
6.8 years), 33 female BN patients (mean age 21.9 ± 3.7 years), and 23
normal controls (CON) (mean age 21.9 ± 3.7 years) with no psychiatric
or physical illness. Patient selection was based on the criteria outlined
in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders;
APA, 1994). BN and AN patients were recruited for the study prior to
treatment through the Eating Disorder Clinic at the Rambam Medical
Center in Haifa, Israel. The study was approved by the Helsinki Com-
mittee for Research Approval) and all participants gave a written in-
formed consent. The three groups were equivalent in terms of parents’
education, socio-economic status, ethnic background, country of birth
(all were native born Israelis), and father’s professional status. Mother’s
professional status was lower in the control group as compared to the
ED groups. In the latter, 47.4% of the mothers in the AN group and
47.8% of the mothers in the BN group worked in academic profession
as compared to 14.3 % of the mothers in the control group.

Measures
Each participant completed two questionnaires:
The Family Environment Scale (FES) (Moos & Moos, 1976). This
measure assesses the individual’s perception of the social-environment
characteristics of her family. It consists of 90 items divided into three
dimensions; Relationship, Personal Growth, and Maintenance. The Re-
lationship dimension comprises Cohesion and Expressiveness sub-
scales. The Cohesion subscale assesses the degree of commitment, help,
and support that family members provide for one another. The Expres-
siveness subscale measures the extent to which family members are
encouraged to act openly and to express their feelings directly. The
 585

YAEL LATZER, ZIPORA HOCHDORF, EITAN BACHAR, AND LAURA CANETTI

dimension of Personal Growth is measured using subscales of Indepen-

dence, Achievement Orientation, Intellectual-Cultural Orientation,
and Active-Recreational Orientation. These subscales assess, respec-
tively: The extent to which family members are assertive, self-suffi-
cient, and make their own decisions; the extent to which activities are
cast into an achievement-oriented or competitive framework; the degree
of interest in political, social, intellectual, and cultural activities; the
extent of participation in social and recreational activities, and; the
degree of emphasis on ethical and religious issues and values.
The Maintenance dimension comprises the Organization and Con-
trol subscales. Respectively, these subscales assess the degree to which
clear organization and structure is emphasized when planning family
activities and responsibilities, and the extent to which set rules and
procedures are used to run family life. Earlier research has shown that
using a subgroup of 49 items from the original FES increases the
reliability of the scale (Hochdorf, 1999). Thus, this subgroup was used
in the present study. All items are rated on a scale of 1 (is very unlike
my family) to 4 (very like my family). The internal consistency scores
(coefficient alphas) were as follows: The Relationship dimension, α =
.93 (Cohesion, α = .91; Expressiveness, α = .85); The Personal Growth
dimension, α = .75 (Independence, α = .54; Achievement, α = .74; Intel-
lectual, α = .53; Active–Recreational, α = .71), and the system Mainte-
nance dimension, α = .68 (Organization, α = .51; Control, α = .70).
The Adult Attachment Scale (AAS) (Hazan & Shaver, 1987). At-
tachment styles were assessed using the Hebrew version of the AAS
(Hazan & Shaver, 1987). This scale is based on the Ainsworth, Blehar,
Waters, and Woll (1978) classification and is widely employed in differ-
ent researches in many countries, including in Israel. The AAS contains
two parts which assess how people typically feel in close relationships
according to three attachment prototypes. In part one, subjects receive
three descriptions of interpersonal relationships and are asked to en-
dorse the one that best describes their own feelings. As a single measure
may be inadequate for classification of attachment style (Hazan &
Shaver, 1987), an additional measure is administered in the second
section in order to obtain concurrent validity. This measure is a rating
scale comprising 15 statements. The statements assess specific charac-
teristics derived from the original prototype descriptions. Subjects rate
the extent to which each statement applies to them on a 6–point scale,
in which 1 = “not at all” and 6 = “very much.” On the basis of the scores
across the test items relating to each attachment style, the dominant
attachment style of the individual was identified. The degree to which
586

CONTEMPORARY FAMILY THERAPY

less prevalent attachment styles characterized the individual was also

determined.

Procedure
The AN and the BN patients were administered the questionnaires
as part of the standard intake evaluation at the clinic. The control
group received the questionnaires at an orientation meeting and filled
them out at home.

Statistical Analyses
The data from the three groups of participants were compared
using ANOVA (analysis of variance) and MANOVA (multiple analysis
of variance) analyses, followed by Tukey post hoc procedures. A logistic
regression was carried out in order to determine if different patterns
of scores on the attachment and family environment measures can
predict ED.

RESULTS

Family Environment
ANOVA analyses were carried out in order to compare AN, BN,
and CON subjects on the FES questionnaire. The results indicated that
the groups differed on the subscales of Cohesiveness, (F(2, 78) = 4.6,
p < .05); Expressiveness, (F(2, 78) = 6.4, p < .01) and the total scale of
Interpersonal relationships, (F(2, 78) = 6.0, p < .01). The subscale of
Independence, (F(2, 78) = 4.7, p < .01) and of Leisure, (F(2, 78) = 11,
p < .001); and the total scale of encouragement for personal growth,
(F(2, 78) = 5.1, p < .01). Means, standard deviations and F values for
each group are presented in Table 1. A Multivariate analysis of variance
(MANOVA) conducted and found to be significant, [F(6, 154) = 2.57,
p < .02]. The results are presented in Table 1.
Tukey tests were carried out in order to determine the source of
these group differences on the different FES subscales. The results
indicated that the levels of family cohesiveness were lower among BN
as compared to controls (p < .05), and that the levels of family expres-
siveness were lower among AN and BN patients as compared to con-
trols, (p < .05). On the total scale of Interpersonal Relationships, family
relationships were reported as being better by controls than by either
 587

YAEL LATZER, ZIPORA HOCHDORF, EITAN BACHAR, AND LAURA CANETTI

TABLE 1
Means, Standard Deviations, and F Values for the Different
Dimensions of FES
AN BN CON F(2,78) Tukey

Cohesiveness Mean 2.88 2.84 3.33 4.6* BN < CON

SD 0.71 0.81 0.60
Expressiveness Mean 2.59 2.57 3.13 6.4** AN < CON > BN
SD 0.78 0.77 0.57
Interpersonal Mean 2.75 2.72 3.24 6.0** AN < CON > BN
relationship SD 0.69 0.76 0.55
Independence Mean 2.85 2.87 3.18 4.7* AN < CON > BN
SD 0.30 0.58 0.42
Achievement Mean 2.81 2.81 2.79 NS
SD 0.48 0.59 0.47
Intellectuality Mean 2.59 2.61 2.71 NS
SD 0.38 0.65 0.52
Leisure Mean 2.42 2.12 2.70 11.0*** CON > BN
SD 0.41 0.56 0.46
Encouragement for Mean 2.67 2.59 2.84 5.1** CON > BN
personal growth SD 0.19 0.39 0.31
Organization Mean 3.01 2.90 3.16 NS
SD 0.38 0.56 0.49
Control Mean 2.50 2.62 2.35 NS
SD 0.58 0.77 0.62
System Mean 2.78 2.78 2.80 NS
maintenance SD 0.35 0.53 0.48

Multivariate F (6, 154) = 2.57, p < .021.

*p < .05; **p < .01; ***p < .001 NS.

group of ED subjects, (p < .05). Control women also rated their families
higher on the Independence subscale than did either ED group, (p <
.05). Encouragement of leisure activities was found to be lower among
BN women than among control women, (p < .05). On total scale of
encouragement of personal growth, CON women rated higher than BN
women, (p < .05).

Attachment Style
Chi-square comparisons were conducted on the data from Part 1
of the AAS, and revealed significant differences in self-reported attach-
588

CONTEMPORARY FAMILY THERAPY

TABLE 2
Self Report of Attachment Styles (in percentages)

AN BN CON

Secure 14.3 30.8 75

Avoidant 50 61.5 21.4
Anxious/Ambivalent 35.7 7.7 3.6
χ2(4) = 22.7, p < .001.

ment style among the three groups of participants, (χ2(4) = 22.7, p <
.001). The data revealed that the most prevalent attachment style of
ED women was the avoidant style, while secure attachment was the
most characteristic of control women. Both BN and AN groups were
characterized by significantly higher levels of avoidant attachment
than were controls. The ED women, mostly AN, scored higher on mea-
sures of anxious attachment than did controls, as well as lower rates
of secure attachment. Table 2 presents the results by percentages.
The same comparisons were conducted on data from Part 2 of the
AAS, referring to the highest score between three attachment styles.
The data revealed that the most prevalent attachment style of the ED
participants was the avoidant style, while secure attachment was the
most characteristic of control women, (χ2(4) = 31.1, p < .001). Table 3
presents the results by percentages.
ANOVA analysis was carried out in order to compare AN, BN, and
CON participants on the AAS questionnaire. The results indicated that
the groups differed on the three attachment styles: Secure, (F(2, 79) =
14.2, p < .001); Anxious, (F(2, 79) = 14.6, p < .001); Avoidant, (F(2, 79) =

TABLE 3
Attachment Styles According to Highest Score Between the Three
(in percentages)

AN BN CON

Secure 29.4 25 88.2

Avoidant 52.9 54.2 8.8
Anxious/Ambivalent 17.6 20.8 2.9
χ2(4) = 31.1, p < .001.
 589

YAEL LATZER, ZIPORA HOCHDORF, EITAN BACHAR, AND LAURA CANETTI

18.7, p < .001). Means standard and F values for each group are pre-
sented in Table 4. A multivariate analysis (MANOVA) was conducted
and found to be significant, [F (6, 156) = 6.56, p < .001]. The results are
presented in Table 4.
Tukey tests were conducted in order to determine whether the 3
groups differed in terms of attachment style on Part 2 of the AAS
questionnaire. Significant differences were found between the control
group and both ED groups on each of the attachment style categories.
Control women were found to be more secure, less avoidant, and less
ambivalent than both groups of ED women. No significant differences
were found among the two ED groups.
In order to determine whether ED could be predicted on the basis
of attachment styles and family environment, a logistic regression anal-
ysis was conducted which included the three attachment styles and
the eight dimensions of family environment. The results revealed that
ED was significantly predicted by ambivalent and avoidant attachment
styles, (B = .88, p < .05; and B = .95, p < .02, respectively), and low en-
couragement of leisure activities, (B = −1.78, p < .01). The factor of
leisure activities was a better predictor of ED (R = −.21) than the Ambiv-
alent (R = .13) or the Avoidant (R = .17) attachment styles. No interac-
tions were found between FES and attachment style.
The model correctly predicted 30 CON subjects within the 37 CON
subjects who participated in the research (e.g., 81%). The model also
correctly predicted that 35 ED participants, within 44 ED who partici-
pated in the research (e.g., 80%), can be considered as having ED

TABLE 4
Mean, S.D. and F Values for Part II of Adult Attachment Scale

AN BN CON F(2,79) Tukey

Secure Mean 3.25 3.42 4.36 14.2*** AN < CON > BN

SD 0.80 0.84 0.90
Anxious/ Mean 3.61 3.73 2.74 14.6*** AN > CON < BN
Ambivalent SD 0.96 0.78 0.70
Avoidant Mean 3.89 4.09 2.80 18.7*** AN > CON < BN
SD 1.04 0.89 0.83
Multivariate F(6, 156) = 6.56, p < .001.
***p < .001.
590

CONTEMPORARY FAMILY THERAPY

problems according to their attachment style and family environment.

The model was statistically significant, (χ2 = 42.4, p < .001).
ANOVA analysis was also conducted using FES while the attach-
ment styles were controlled. The difference in family environment dis-
appeared when attachment style was controlled, [F (6, 148) = 1.85,
p = 0.9 (NS)]. According to this finding, attachment issues may reflect
a major underlying dynamic in family functioning.
Thus, these variables may be useful as markers for identifying
individuals at risk for ED. Anorexic and bulimic women exhibited a
specific pattern; they both were characterized by anxious and avoidant
attachment styles, and described their families as less encouraging of
leisure time.

DISCUSSION

The results revealed no significant differences between AN and

BN patients on any dimension of the FES or the AAS. The finding
that these two groups were similar in terms of family functioning is
consistent with some studies (Leon et al., 1985; Thienmann & Steiner,
1993) but not with others (Felker & Stivers, 1994; Hodges et al., 1998;
Stern et al., 1997; Strober, 1981). One explanation of the diverse find-
ings in the literature regarding ED subgroups is that while there may
be no essential difference between the underlying psychopathology of
AN and BN, there are differences in the external manifestation of
symptoms. Current conceptions view ED as an umbrella term for sev-
eral kinds of eating problems (APA, 1994). According to this view, all
EDs share certain commonalties. Moreover, symptoms of both distur-
bances may be found concurrently in a particular individual (Trea-
sure & Campbell, 1994). In clinical practice, it is often hard to distin-
guish between these disturbances because transitions are often made
between AN and BN. For instance, a patient may be initially classified
as anorexic, and some months later better fit the criteria for bulimia
(Garner & Garfinkel, 1997).

Family Environment
One source of similarity between the two ED groups may be the
existence of common family dynamics underlying the development of
both disorders. As indicated in a study by Latzer and Gaber (1998),
these similarities may be associated with specific styles of communica-
 591

YAEL LATZER, ZIPORA HOCHDORF, EITAN BACHAR, AND LAURA CANETTI

tion and conflict avoidance in the family. The present findings on the
family environment measures are consistent with this interpretation,
in that both groups of ED patients rated their families significantly
lower than did normal controls on the Personal Relationships dimen-
sion of the FES. This was true of both the Cohesiveness and Expressive-
ness subscales. Previous work employing the FES has obtained similar
results (Johnson & Flach, 1985; Leon et al., 1985; Strober, 1981).
The present results also revealed that ED patients scored signifi-
cantly lower than did normal controls on the dimension of Personal
Growth, particularly with respect to family encouragement of leisure
activities. Logistic regressions indicated that the extent to which fami-
lies encourage leisure activities might serve as a discriminative marker
for ED. This proposal is in line with theoretical approaches emphasizing
the importance of the “conflict free” ego in the individuation and separa-
tion processes characteristic of adolescence. According to this position,
these processes can proceed normally only when the ego can is able to
function efficiently, creatively, and without restraint (Erickson, 1968).
The idea that the encouragement of independence is critical to the
psychological functioning of the adolescent is supported in previous
research. A number of studies have shown that families who emphasize
independence enable the adolescent to develop a clear identity. Such
families are able to provide support during social and developmental
transitions such as adapting to situations like entering college (Holm-
beck & Wandrei, 1993; Lapsley, Rice & Shadid, 1989) or the army
(Hochdorf, 1999).
According to Bruch (1973), one of the central characteristics of the
psychopathology of anorexia is the failure of the adolescent girl to
develop autonomy and separation from parental figures, especially the
mother. In AN, maternal intrusiveness and control is typical of the
mother-daughter relationship. However, the variables of separation
and individuation are difficult to measure. One reason for this is that
discussing the source of the problem is often perceived as threatening
and intrusive by different members of the family, who feel ashamed
and guilty and frequently deny the existence of the syndrome (Garner &
Garfinkel, 1997; Maddocks & Kaplan, 1991). Assessing the aspect of
leisure activities in the family may be an expedient way to obtain
important information about family dynamics and issues of control,
without arousing resistance, anxiety, or denial. Nevertheless, as earlier
work examining the dimension of personal growth has not obtained
evidence of a relationship to ED, additional research is needed in this
area (Lyon et al., 1997; Stern et al., 1997; Strober, 1981).
592

CONTEMPORARY FAMILY THERAPY

Attachment Style
As mentioned, no significant differences were found between the
two ED subgroups in terms of attachment styles. The results also
revealed a significant difference between normal and ED women’s at-
tachment styles. Secure attachment was more frequent among normal
women, whereas anxious and avoidant attachment styles were more
common among ED women. These findings are compatible with those
of other studies (Evans & Wertheim, 1997; Friedberg & Lyddon, 1996),
despite the use of different methods.
According to Bowlby (1969, 1973, 1980), during the process of at-
tachment “internal working models” are created regarding the concept
of the self, others, and the external environment. These “internal mod-
els” dictate the individual’s behavior in different situations. In this
study, attachment styles were examined in adulthood. Therefore, only
tentative conclusions may be drawn regarding the early relationship
between the child and the caretaker, and the continuity of attachment
issues over time. Nonetheless, it has long been held that one style of
attachment usually predominates, and is thought to represent the most
frequently experienced or more accessible attachment orientation
(Bowlby, 1973).
Recent studies support this idea, and suggest that a dominant
mode may coexist with other styles in a hierarchical network that
is activated differentially in varying contexts (Collins & Read, 1994;
Mikulincer & Arad, 1999). Therefore, it is likely that the attachment
classifications obtained in the present study did represent the partici-
pants’ dominant style. It is also highly probable that in the majority
of the subjects, this dominant mode was formed by factors in the early
childhood environment. On the basis of the finding that these adult
ED subjects were less secure, and more anxious and avoidant, it is pro-
posed that regardless of the time of assessment, the individual’s dominant
style of attachment may serve as an additional marker of ED.
As both family environment (Armstrong & Roth, 1989; Chassler,
1997; Johnson & Flach, 1985; Leon et al., 1985; Strober, 1981) and
attachment styles (Cole-Detke & Kobak, 1996; Evans & Werteim, 1997;
Friedberg & Lyddon, 1996; Kenny 1991) have been found to discrimi-
nate between ED and normal controls in previous studies. However
the association between these two variables was not examined. The
research finding suggests that when problems of attachment combine
with other aspects of dysfunctional family, the risk of developing an
ED is increased.
 593

YAEL LATZER, ZIPORA HOCHDORF, EITAN BACHAR, AND LAURA CANETTI

Supporting the idea of a close association between family environ-

ment and attachment style was the finding that differences in family
environment disappeared when attachment style was controlled. The
implication of this finding is that the attachment issues may reflect a
major underlying dynamic in family functioning.
These findings suggest that attachment style may be a primary
differentiating factor in the etiology of ED. They also suggest that other
aspects of the family environment (such as those measured on the FES)
may be insufficient in themselves to the understanding of ED, but more
informative when used in combination with measures of attachment.
Conceivably, it is the interaction between the two factors that deter-
mines the development of ED. If this finding is replicable, it may provide
important insight into the processes underlying ED.
Further examination of the association between the different di-
mensions of family functioning and attachment style among ED pa-
tients was achieved using a logistic regression analysis. The results
indicated that low encouragement of personal growth interacted with
high scores of avoidant and anxious attachment styles can be considered
as a discriminating and predictive factor of ED (Bachar, 1998; Bruch,
1970; Goodsitt, 1986; Minuchin et al., 1975). This finding might also
be accounted for in the context of attachment theory. According to
Bowlby (1973), the securely attached child is able to freely explore
his or her environment because he or she knows that the primary
attachment figure will be available, attentive, and attuned to his or
her needs whenever necessary. Possibly, low encouragement of environ-
mental exploration by the child may be associated with general low
encouragement of personal growth. Both may be manifested in the
insecure attachment styles characteristic of ED patients. Nevertheless,
while this trend was evident in the present study, it is still premature to
reach definite conclusions and additional work on this issue is needed.

Limitations
In this study, self-report measures were used. A more complete
picture of family dynamics may be obtained by comparing parents’
perceptions of attachment and family environment variables with those
of the patients. Previous research on normal populations comparing
parents’ and adolescents’ perceptions of their families has obtained
evidence of gaps between the two. Compared to adolescents, parents
reported higher levels of flexibility, cohesiveness, development, involve-
ment and support, and lower levels of conflict (Ohannessian-McCauley &
594

CONTEMPORARY FAMILY THERAPY

Lerner, 1995; Noller & Callan, 1986; Smetana, 1988). These gaps have
been interpreted as resulting from a heavy emotional investment in
the family by the parents, and from their tendency to see the family
in a positive light. Conversely, adolescents relate to their families from
a different perspective, namely, from the viewpoint of the psychological
processes occuring during adolescence. At this age, the need for individ-
uation and the definition of a personal identity are emphasized (Marcia,
1980). Adolescents have the task of becoming independent and accept-
ing responsibility for their own decisions and actions, while maintain-
ing a close relationship with their parents (Noller & Collan, 1991). As
mentioned, in families in which the girl is suffering from an ED, the
symptoms are manifested, in part, in difficulty with the process of
separation, the development of an independent identity, and the ability
to make decisions. Whether similar gaps are reported by ED adolescents
and their parents may contribute to a greater understanding of this
issue. Additional research is also needed to determine whether the
attachment difficulties characteristic of ED populations are signifi-
cantly different from those of other clinical populations.

THERAPEUTIC IMPLICATIONS

The findings of this study emphasize the importance of the inter-

personal relationships among family members in the etiology of ED.
The results particularly implicate parental caregiving in terms of the
development of secure attachment. It has been long held that insecure
attachment may lead to avoidance and conflict issues, thereby evoking
emotional problems in the adolescent (Bowlby, 1969, 1973). On the
basis of this idea, it has been proposed that eating disorders divert the
adolescent’s attention away from attachment-related concerns toward
the more external and more attainable goal of body image (Cole-Detke &
Kobak, 1996; Dozier, Stovall & Albus, 1999). Eating disorders may
result from a need for control and independence, together with a search
for an external means of coping with internal conflict.
The results of the current study suggests that need to feel secure
within the family environment may be critical to the understanding of
ED individuals. Thus, focusing on the externalizing factors of food
and body image may be less a beneficial avenue of treatment than
responding to the underlying need to feel secure. It is suggested that
creating an internal sense of security should be the focal point of the
therapeutic interaction.
In light of the importance of familial factors in the etiology of ED,
 595

YAEL LATZER, ZIPORA HOCHDORF, EITAN BACHAR, AND LAURA CANETTI

family therapy is also recommended. Family therapy can be used as a

framework for changing the family attachment styles through exposure
of the beliefs and rules that dictate and influence family functioning,
and through introducing new ways of interaction that promote family
stability. New emotional experiences that occur in transformed interac-
tions with attachment figures may be a powerful way to effect intrapsy-
chic and interpersonal change (Johnson, Maddeaux, & Blouin, 1998).
In addition, warm and emphatic feelings interactions with the therapist
may act as a “healing experience,” thereby helping to achieve a more
secure attachment style (Byng-Hall & Stevenson-Hinde, 1991; Byng-
Hall, 1995).
Family therapy may be a critical aspect of treating ED adolescents.
In our opinion, one way in which to help the patient develop a sense
internal security and autonomy of the self is through providing round-
the-clock availability, acceptance, support, and containment to the par-
ents during the first 3 months of treatment (during which the parents
receive instruction regarding the feeding of their children). This view-
point is based on the assumption that when the parents themselves
feel a sense of safe communication with the therapist, they will be able
to transmit this feeling to their children. When the parents feel they
are contained and supported rather than guilt-ridden and insecure,
they may be become more aware of their own strengths and abilities,
and become better able to take initiative. Thus, the therapeutic rela-
tionship can provide a new sense of independence and autonomy to the
ED adolescent, through the provision of support and containment to
the parents.
This approach is in line with the Emotionally Focused Therapy
(EFT) model described by Johnson (2002).
This family orientation therapy addressed attachment issues in
the therapeutic processes by shifting negative cycles to cycles character-
ized by affiliation and trust, and foster a creation of a secure attachment
bond (Johnson, Maddeaux, & Blouin, 1998; Millkin & Johnson, 2000).
In terms of diagnosis, as mentioned before, the extent to which
personal growth is encouraged in the family, together with an insecure
attachment style, may serve as a marker for ED. Individuals who
display this pattern may be at risk for the development of ED.

REFERENCES

Ainsworth M. D. (1989). Attachment beyond infancy. American Psychologist, 44, 709–716.

Ainsworth M. D., Blehar, M. C., Waters, E., & Woll, S. (1978). Patterns of attachment:
A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.
596

CONTEMPORARY FAMILY THERAPY

American Psychiatric Association. (1994). Statistical and diagnostic manual of mental

disorders (DSM-IV). Washington, DC: Author.
Armstrong, J. G., & Roth, D. M. (1989). Attachment and separation difficulties in eating
disorders: A preliminary investigation. International Journal of Eating Disorders,
8, 141–155.
Bachar, E. (1998). The contribution of self psychology to the treatment of anorexia and
bulimia. American Journal of Psychotherapy, 52, 147–165.
Bartholemew, K., & Horwitz, L. M. (1991). Attachment styles among young adults: A
test of a four category model. Journal of Personality and Social Psychology, 61,
226–244.
Beumont. P.J.V., Russell, J. D., & Touyz, S. W. (1993). Treatment of anorexia nervosa.
The Lancet, 26, 341–346.
Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books.
Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation: Anxiety and anger. New York:
Basic Books.
Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss. New York: Basic Books.
Bowlby, J. (1988). A secure loss: Clinical applications of attachment theory. London:
Routledge.
Brennan, K. A., & Shaver, P. R. (1995). Dimensions of adult attachment, affect regulation
and romantic relationship functioning. Personality and Social Psychology Bulletin,
21, 267–283.
Brookings, J. B., & Wilson, J. F. (1994). Personality and family-environment predictors
of self-reported eating attitudes and behaviors. Journal of Personality Assessment,
63, 313–326.
Bruch, H. (1970). Family background in eating disorders. In E. J. Anthony & C. Kouper-
nick (Eds.), The child and his family (pp. 285–309) New York: Wiley-Interscience.
Bruch, H. (1973). Eating disorders: Obesity, anorexia nervosa, and the person within.
New York: Basic Books.
Byng-Hall, J. (1995). Creating a secure family base: Some implications of attachment
theory for family therapy. Family Process, 34, 45–58.
Byng-Hall, J., & Stevenson-Hinde, J. (1991). Attachment relationships with a family
system. Infant Mental Health Journal, 12, 187–200.
Chassler, L. (1997). Understanding anorexia nervosa and bulimia nervosa from an attach-
ment perspective. Clinical Social Work Journal, 25, 407–423.
Cole-Detke, H., & Kobak, R. (1996). Attachment process in eating disorder and depression.
Journal of Consulting and Clinical Psychology, 64, 282–290.
Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship
quality in dating couples. Journal of Personality and Social Psychology, 58, 644–663.
Collins, N. L., & Read, S. J. (1994). Cognitive representations of attachment: The struc-
ture and function of working models. In K. Bartholemew, & D. Perlman (Eds.),
Attachment Process in Adulthood (pp. 53–90). London: Jessica Kingsley.
Crisp, A. H., Harding, B., & McGuiness, B. (1974). Anorexia nervosa. Psychoneurotic
characteristics of parents: relationship to prognosis. A quantitative study. Journal
of Psychosomatic Research, 18, 167–173.
Dare, C., Eisler, I., Russel, G. F. M., & Szmukler, G. I. (1990). The clinical and theoretical
impact of a controlled trail of family therapy in anorexia nervosa. Journal of Marital
and Family Therapy, 16, 39–57.
Dare, C. Le Grange, D., Eisler, I., & Rutheford J. (1994). Redefining the psychosomatic
family: family process of 26 eating disorder families. International Journal of Eating
Disorders, 16, 211–226.
Deter, H. C., Herzog, W., & Manz, R. (1994). Do patient with anorexia nervosa return
to psychological health? Results of a 12-year follow-up of 103 patients. [German].
Zeitschrift fur Psychosomatische Medizin und Psychoanalyse, 40, 155–173.
Dozier, M., Stovall, K. C., & Albus, K. E. (1999). Attachment and psychopathology in
 597

YAEL LATZER, ZIPORA HOCHDORF, EITAN BACHAR, AND LAURA CANETTI

adulthood. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment theory:

Research and clinical applications (pp. 497–519). New York: Guilford Press.
Eckert, E. D., Halmi, K. A., Marchi, P., Grove, W., & Crosby, R. (1995). Ten-year follow-
up of anorexia nervosa: clinical course and outcome. Psychological Medicine, 25,143–
156.
Erickson, E. H. (1968). Identity: Youth and crisis. New York: Norton.
Evans, L., & Wertheim, E. H. (1997). Intimacy patterns and relationship satisfaction of
women with eating problems and the mediating effects of depression, trait anxiety
and social anxiety. Journal of Psychosomatic Research, 44, 355–365.
Felker, K. R., & Stivers, C. (1994). The relationship of gender and family environment
to eating disorder risk in adolescents. Adolescence, 29, 820–834.
Friedberg, N. L., & Lyddon, W. J. (1996). Self–other working models and eating disorders.
Journal of Cognitive Psychotherapy: An International Quarterly, 10, 193–203.
Friedlander, M. L., & Siegel, S. M. (1990). Separation-individualization difficulties and
cognitive-behavioral indicators of eating disorders among college women. Journal
of Counseling Psychology, 37, 74–78.
Garfinkel, P. E., & Garner, D. M. (1982). Anorexia nervosa: A multidimensional perspec-
tive. New York: Brunner/Mazel.
Garner, D. M., & Garfinkel, P. E. (Eds.) (1997). Handbook of treatment for eating disorders
(2nd ed.). New York: Guilford Press.
Goodsitt, A. (1986). Self psychology and the treatment of anorexia nervosa. In D. M.
Garner & P. E. Garfinkel (Eds.), Handbook of psychotherapy for anorexia and bulimia
(pp. 205–228). New York: Guilford Press.
Hazan, C., & Shaver, D. (1987). Romantic love conceptualized as an attachment process.
Journal of Personality and Social Psychology, 52, 511–524.
Head, S. B., & Williamson, D. A. (1990). Association of family environment and personal-
ity disturbance in bulimia nervosa. International Journal of Eating Disorders, 9,
667–674.
Heesacker, R. S., & Neimeyer, G. F. (1990). Assessing object relations and social cognitive
correlates of eating disorder. Journal of Counseling Psychology, 37, 419–426.
Herzog, D. B., Greenwood, D. N., Dorer, D. J., Flores, A. T., Ekeblad, E. R., Richards,
A., Blais, M. A.. & Keller, M. B. (2000). Mortality in eating disorders: A descriptive
study. International Journal of Eating Disorders, 28, 20–26.
Hobbs, W. L., & Johnson, C. N. (1996). Anorexia nervosa: An overview. American Family
Physician, 54,1273–1279.
Hochdorf, Z. (1999). Relationships between family environment, parental reaction toward
“launching” and personal variables of soldiers in training. Unpublished doctoral
dissertation. Haifa University, Israel.
Hodges, E. L., Cochrane, C. E., & Brewerton, T. D. (1998). Family characteristics of binge-
eating disorder patients. International Journal of Eating Disorders, 23, 145–151.
Holmbeck, G. N. & Wandrei, M. L. (1993). Individual and relational predictors of adjust-
ment in first year college students. Journal of Counseling Psychology, 40, 73–78.
Humphrey, L. L. (1986). Family relationships in bulimic-anorexic and nondistressed
families. International Journal of Eating Disorders, 5, 223–232.
Humphrey, L. L. (1987). Comparison of bulimic-anorexic and non-distressed families
using structural analysis of social behavior. Journal of the American Academy of
Child and Adolescent Psychiatry, 26, 248–255.
Humphrey, L. L. (1988). Relationship within subtypes of anorexic, bulimic and normal
families. Journal of the American Academy of Child and Adolescent Psychiatry, 27,
544–551.
Johnson, C., & Flach, A. (1985). Family characteristics of 105 patients with bulimia.
American Journal of Psychiatry, 142, 1321–1324.
Johnson, S. M. (2002). Emotionally focused couple therapy with trauma survivors: Treat-
ing attachment bonds. New York: Guilford Press.
598

CONTEMPORARY FAMILY THERAPY

Johnson, S. M., Maddeaux, C., & Blouin, J. (1998). Emotionally focused family therapy
for bulimia: Changing attachment patterns. Psychotherapy, 35, 238–247.
Kagan, D., & Squires, R. (1985). Family cohesion, family adaptability and eating disor-
ders. International Journal of Eating Disorders, 4, 267–279.
Kenny, M. (1991, July). Attachment and eating disorders. Paper presented at the annual
convention of the American Psychological Association. San Francisco.
Kenny, M., & Hart, K. (1992). Relationship between parental attachment and eating
disorders in an inpatient and college sample. Journal of Counseling Psychology, 39,
521–526.
Kobak, R., & Cole, H. (1994). Attachment and meta-monitoring: Implications for adoles-
cent autonomy and psychopathology. In D. Cicchetti & S. L. Toth (Eds.), Rochester
Symposium on developmental psychopathology: Disorders and disfunctions of the
self (Vol 5, pp. 267–297). Rochester, NY: University of Rochester Press.
Kog, E., & Vandereycken, W. (1989). Family interaction in eating disorder patient and
normal controls. International Journal of Eating Disorders, 8, 11–23.
Kog, E., Vandereycken, W., & Vertommen, H. (1985a). Towards a verification of the
psychosomatic family model: A pilot study of ten families with an anorexia/bulimia
nervosa patient. International Journal of Eating Disorders, 4, 525–538.
Kog, E., Vandereyckern, W., & Vertommen, H. (1985b). The psychosomatic family model:
A critical analysis of family interaction concepts. Journal of Family Therapy, 7,
31–44.
Lapsley, D. K., Rice, K. G., & Shadid, G. E. (1989). Psychological separation and adjust-
ment to college. Journal of Counseling Psychology, 36, 286–294.
Latzer, Y. (1993). Patterns of verbal communication among parents of anorectic female
adolescents. Unpublished research thesis for D.Sc., Israel Institute of Technology,
Haifa, Israel.
Latzer, Y. & Gaber, L. B. (1998). Pathological conflict avoidance in anorexia nervosa:
family perspectives. Contemporary Family Therapy, 20, 539–551.
Leon, G. R., Lucas, A. R., Colligan, R. C., Ferdinande, R. J., & Kamp, J. (1985). Sexual,
body image, and personality attitudes in anorexia nervosa. Journal of Abnormal
Child Psychology, 13, 245–258.
Lyon, M., Chatoor, I., Atkins, D., Silber, T., Mosimann, J., & Gray, J. (1997). Testing
the hypothesis of the multidimensional model of anorexia nervosa in adolescents.
Adolescence, 32, 101–111.
Maddocks, S., & Kaplan, A. S. (1991). The prediction of positive treatment response in
bulimia nervosa: A study of patient variables. British Journal of Psychiatry, 159,
846–849.
Marcia, E. J. (1980). Identity in adolescence. In J. Adellson (Ed.), Handbook of adolescent
Psychology (pp. 159–187). New York: Wiley.
Mazor, M. (1994). The connection between attachment styles and family types. Unpub-
lished master’s thesis, Bar Ilan University, Israel.
Mikulincer, M., & Arad, D. (1999). Attachment working models and cognitive openness
in close relationships: A test of chronic and temporary accessibility affects. Journal
of Personality and Social Psychology, 77, 710–725.
Mikulincer, M., & Florian, V. (1995). Appraisal of and coping with a real stressful
situation: The contribution of attachment styles. Personality and Social Psychology
Bulletin, 21, 406–414.
Mikulincer, M., & Florian, V. (1998). The relationship between adult attachment styles
and emotional and cognitive reactions and stressful events. In J. A. Simpson & W.
S. Rhodes (Eds.), Attachment theory and close relationships (pp. 143–165). New
York: Guilford Press.
Mikulincer, M., & Horesh, N. (1999). Adult attachment style and perception of others:
The role of protective mechanisms. Journal of Personality and Social Psychology,
76, 1022–1034.
 599

YAEL LATZER, ZIPORA HOCHDORF, EITAN BACHAR, AND LAURA CANETTI

Mikulincer, M., & Nachshon, O. (1991). Attachment styles and patterns of self disclosure.
Journal of Personality and Social Psychology, 61, 321–331.
Mikulincer, M., & Orbach, I. (1995). Attachment styles and repressive defensiveness:
the accessibility and architecture of affective memories. Journal of Personality and
Social Psychology, 68, 917–925.
Millikin, J. W., & Johnson, S. M. (2002). Telling tales; Disquisitions in emotionally
focused therapy. Journal of Family Psychotherapy, 11, 75–79.
Minuchin, S., Baker, B. L., Rosman, B. L., Milman, L., & Todd, T. C. (1975). A conceptual
model of psychosomatic illness in children: Family organization and family therapy.
Archives of General Psychiatry, 32, 1031–1038.
Minuchin, S., Rosman, B. L., & Baker, B. L. (1978). Psychosomatic families: Anorexia
nervosa in context. Cambridge, MA: Harvard University Press.
Moos, R. H., & Moos, B. S. (1976). A typology of family social environment. Family
Process, 15, 357–371.
Neumarker, K. J. (1997). Mortality and sudden death in anorexia nervosa. International
Journal of Eating Disorders, 21, 206–212.
Noller, P. & Callan. (1986). Adolescence and parent perceptions of family cohesion and
adaptability. Journal of Adolescence, 9, 97–106.
North, C., Giwers, S., & Byram, V. (1995). Family functioning in adolescent anorexia
nervosa. British Journal of Psychiatry, 167, 673–678.
Ohannessian-McCauley, C., Lerner, R. M., Lerner, J. V., & Von Eye, A. (1995). Discrepan-
cies in adolescents’ and parents’ perceptions of family functioning and adolescent
emotional adjustment. Journal of Early Adolescence, 15, 490–516.
Ordman, A. M., & Kirschenbaum, D. S. (1986). Bulimia: Assessment of eating, psychologi-
cal adjustment and familial characteristics. International Journal of Eating Disor-
ders, 5, 865–878.
Rice, K. G., Fitzgerald, D. P., Whaley, T. J., & Gibbs, C. L. (1995). Cross-sectional
and longitudinal examination of attachment, separation-individuation and college
student adjustment. Journal of Counseling and Development, 73, 463–474.
Selvini-Palazzoli, M. (1974). Self-starvation: From the interpsychic to the transpersonal.
London: Chancer Press.
Smetana, J. G. (1988). Adolescents and parents conceptions of parental authority. Child
Development, 59, 321–335.
Stern, S. L., Dixon, K. N., Jones, D., Lake, M., Nemzer, E., & Sansone, R. (1997). Family
environment in anorexia nervosa and bulimia. Unpublished manuscript.
Strober, M. (1981). The significance of bulimia in juvenile anorexia nervosa: An explana-
tion of possible etiologic factors. International Journal of Eating Disorders, 1, 28–43.
Strober, M., & Humphrey, L. L. (1987). Familial contribution to the etiology and course
of anorexia nervosa and bulimia. Journal of Counseling and Clinical Psychology,
55, 654–659.
Szmukler, G. I., Eisler, I., Russel, G. F. M. & Dare, C. (1985). Anorexia nervosa, parental
“expressed emotion” and dropping out of treatment. British Journal of Psychiatry,
147, 265–271.
Thienmann, M. & Steiner, H. (1993). Family environment of eating disordered and
depressed adolescents. International Journal of Eating Disorders, 14, 43–48.
Treasure, J. & Campbell, C. (1994). The case for biology in the etiology of anorexia
nervosa. Psychological Medicine, 24, 3–8.

View publication stats