Attachment, Assessment, and Psychological

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Attachment, Assessment, and Psychological Intervention: A Case Study of Anorexia a

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Adriana Lis , Claudia Mazzeschi , Daniela Di Riso & Silvia Salcuni

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Department of Psychology, University of Padua, Italy

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Department of Human Science and Education, University of Perugia, Italy

Available online: 22 Aug 2011

To cite this article: Adriana Lis, Claudia Mazzeschi, Daniela Di Riso & Silvia Salcuni (2011): Attachment, Assessment, and Psychological Intervention: A Case Study of Anorexia, Journal of Personality Assessment, 93:5, 434-444 To link to this article: http://dx.doi.org/10.1080/00223891.2011.594125

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Journal of Personality Assessment, 93(5), 434–444, 2011 C Taylor & Francis Group, LLC Copyright ISSN: 0022-3891 print / 1532-7752 online DOI: 10.1080/00223891.2011.594125

SPECIAL SECTION: Clinical Applications of the Adult Attachment Projective

Attachment, Assessment, and Psychological Intervention: A Case Study of Anorexia ADRIANA LIS,1 CLAUDIA MAZZESCHI,2 DANIELA DI RISO,1 AND SILVIA SALCUNI1 1

Department of Psychology, University of Padua, Italy Department of Human Science and Education, University of Perugia, Italy

Downloaded by [Universita di Padova] at 04:31 06 February 2012

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Attachment patterns and personality dimensions have always been considered important to the development and adaptation of the individual. The first aim of this article was to address some basic questions about the place of attachment in a multimethod assessment when compiling a complete picture of the patient’s personality functioning. The second aim was to present the Adult Attachment Projective Picture System (AAP; George & West, 2001) as a valid and productive assessment measure. Based on a single case study of an anorexic young woman, the article demonstrates how the AAP is integrated with the Rorschach Comprehensive System (Exner, 1991, 1993) and other assessment tools in both the assessment and in developing a treatment plan.

Attachment theory in the tradition of Bowlby (1969, 1973, 1980) and Ainsworth (1963, 1967) postulates that an individual’s experiences of early parental care contribute to the development of internal representations of the self and others as safe and available. One of the main questions about attachment concerns possible relationships among patterns of attachment, normal development, adaptation, and psychopathology (Cassidy & Shaver, 2008). The essential link between attachment and adaptation raises several important questions for clinicians: Are attachment patterns a dimension of personality? How is attachment connected or interwoven with other personality dimensions? How, and how much, should a clinician rely on attachment to complete a picture of the patient’s personality functioning? Assessment using validated attachment measures provides the indispensable methodological background needed to correctly integrate attachment in clinical contexts. Such assessment identifies unique information about a person’s attachment pattern. However, no single assessment measure is sufficiently comprehensive on its own to provide a complete picture of personality, unambiguous information about overt behavior, or reasonable and individualized predictions (Meyer & Archer, 2001). No single variable, score, or ratio can be interpreted in isolation from history, response style, and other data (Gacono, Nieberding, Owen, Rubel, & Bodholdt, 2001). A number of researchers emphasize the importance of using a number of different methods when examining a client (e.g., Gacono et al., 2001; Meyer & Archer, 2001; Meyer, Finn, Eyde,

Received March 25, 2010; Revised September 14, 2010. Address correspondence to Adriana Lis, Department of Psychology, University of Padua, c/o LIRIPAC, Via Belzoni, 80, 35100 Padova, Italy; Email: [email protected]

Kubiszyn, & Moreland, 1998). A multimethod assessment approach provides incremental validity by adding information from different methods (Funder, 1997; Mattlar, 2001; Meyer & Archer, 2001; Meyer et al., 1998; Ozer, 1999). Only a few, however, have addressed the interplay between attachment pattern measures and more traditional multimethod assessments in clinical settings (Buchheim, 2005; Buchheim & Kachele, 2001; Dahlbender, Buchheim, & Doering, 2004; Isaac, George, & Marvin, 2009; Lis, Mazzeschi, Salcuni, & Di Riso, 2008). The aim of this article is to present an assessment case study of anorexia focusing on the evaluation of attachment patterns. There is a fairly substantial theoretical and empirical literature on relationships between attachment and anorexia (e.g., Hochdorf, Latzer, Canetti, & Bachar, 2005; O’Shaughnessy & Dallos, 2009; Ward, Ramsay, Turnbull, & Steele, 2001). However, multimethod clinical assessment case studies of anorexia are scarce. This case study involves a young woman with anorexia nervosa. A multimethod approach is used to gain incremental validity in understanding her. The article demonstrates the use of a performance-based attachment measure and integrates the findings with information from the Rorschach, the Symptom Checklist–90–Revised (SCL–90–R; Derogatis & Lazarus, 1994), the Body Uneasiness Test (BUT; Cuzzolaro, Vetrone, Marano, & Garfinkel, 2006), and a psychodynamic clinical interview. After a brief presentation of the case, the multimethod battery and the results of each measure are described. The assessment tools were then integrated to formulate a case conceptualization and treatment plan, according to Bihlar and Carlsson’s (2000) goal categories. Specifically, we discussed how the intersection of the Adult Attachment Projective Picture System (AAP; George & West, 2001, in press), Rorschach, and other information collected during assessment can provide a clear picture of a patient’s personality functioning and adaptation.

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ATTACHMENT, ASSESSMENT, AND INTERVENTION THE CASE Emily is a 17-year-old girl, the first of two children in an intact family. Her mother is 45 and her father is 50 years old, and both are very involved in their jobs. Her father is in the army and he is described as being cold and strict, whereas her mother, a social worker, is described as more affectionate. Emily was diagnosed at the age of 15 with anorexia nervosa according to Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association, 1994) criteria. It was determined that she was an anorectic restrictive type, with periods of elimination behavior (bulimic crisis, diuretic abuse), depressive and anxiety symptoms, obsessive behaviors, and high interpersonal sensitivity. At that time she had been hospitalized for 6 months. We saw her 2 years later at the age of 17. She was 5 feet tall and was again very underweight (70 pounds), with a body mass index of 13. Because of this severe condition, she had been admitted to a clinic for eating disorders. A multimethod psychological assessment was requested to acquire more specific knowledge of her functioning and to decide on a psychological treatment plan. THE MULTIMETHOD ASSESSMENT BATTERY The Adult Attachment Projective Picture System The AAP (George & West, 2001) is based on an analysis of responses to a standardized set of seven drawn picture stimuli. The scenes portray children or adults alone (alone pictures) or in attachment-caregiving dyads (dyadic pictures). The stimuli represent major attachment events, including illness, solitude, separation, death, and abuse. Individuals are asked to make up a story for each image in which they describe what is going on in the picture, what led to the scene, what the characters are thinking or feeling, and what might happen next. The AAP is a recent addition to assessing attachment in the Bowlby–Ainsworth tradition (West & George, 2002) and the picture stimuli are hypothesized to elicit attachment anxiety. The AAP examines how individuals make sense of the various attachment scenes depicted by using their perceptual and affective responses to give meaning to the picture stimuli. It also assesses the personal elements of attachment that individuals might exclude from conscious awareness. The AAP leads to four adult attachment classification groups, analogous to the adult classification groups—secureautonomous, dismissing, preoccupied, and unresolved—as they were traditionally assessed during the structured Adult Attachment Interview (AAI; George, Kaplan, & Main, 1984, 1985, 1996; Hesse, 2008). Each AAP transcript is coded on seven scales grouped under the three major categories of discourse, content, and defensive processing. Discourse codes evaluate personal experience, which indicates whether or not the individual’s stories include statements regarding his or her own life experiences. Personal experience indicates a loss of distance from the stimulus. Content codes include agency of self and connectedness for alone pictures, and synchrony for dyadic pictures. Agency of self captures the individual’s representation of the self as capable of drawing on internalized attachment resources or tangible and available attachment figures to help cope with distress. It also captures the individual’s representation of the self as able to engage in constructive problem-solving action.

435 Connectedness evaluates how the individual feels connected to others in meaningful attachment, friendship, or partnered relationships. Synchrony assesses the degree to which the story characters are portrayed in a reciprocal and mutually engaging relationship (George & West, in press). Finally, we address the AAP codes for defensive exclusion. Bowlby (1980) defined defensive exclusion as a psychological process where most of the information reaching an individual is excluded from further processing to prevent the overloading of his or her capacities and attention. This information can be stored for relatively long periods or even permanently. There are three form of defensive exclusion: segregated systems, deactivation, and cognitive disconnection. They represent different degrees of “protection” from dangerous distressful events. Segregated systems describe a mental state in which painful attachment-related memories are isolated and blocked from conscious thought and rooted in experiences of trauma or loss through death (Bowlby, 1980). Segregated systems are coded for story content that emphasizes, for instance, danger-failure protection, odd-disturbing material and emptiness. Deactivating defensive processes are defined as attempts to dismiss, cool off, or shift attention away from attachment events, individuals, or feelings in response to the picture stimuli. The aim of deactivation is to produce a representational “distance” between the individual and the attachment-activating event. Deactivation works to neutralize the attachment distress. It is coded for story themes that emphasize the importance, for instance, of rules, achievement, authority, or distance. Cognitive disconnection processes literally disconnect the elements of attachment from their source, thus undermining consistency and the capability of holding in one’s mind a unitary view of events, emotions, and individuals associated with them. “Fragmentation” prevents the individual from seeing and therefore responding affectively to the stimulus distress. Cognitive disconnection is coded for story themes that emphasize the importance of, for instance, uncertainty, withdrawal, and glossing over. Using these seven dimensions, one of four attachment classifications is assigned. Individuals classified as secure are characterized by a representation of a self capable of relying on internalized attachment resources or available attachment figures to help cope with distress. Security also captures the individual’s feelings of being connected to others in meaningful attachment, friendship, or partnered relationships and the ability to represent himself or herself in a reciprocal and mutually engaging relationship. Secure individuals show little use of defensive processes. Individuals classified as dismissing show an individual’s representation of the self mostly able to engage in constructive problem-solving action. They describe interpersonal themes that often fail to represent a reciprocal and mutually engaging relationship. They rely heavily on the deactivation form of defensive exclusion in their stories. In individuals classified as preoccupied, personal experiences frequently invade the stories. They are typically unable to rely on internalized attachment resources or to engage in constructive problem-solving action to cope with attachment anxiety. They show a low level of connectedness and synchrony and use the cognitive disconnection form of defensive exclusion in their stories. As a result of this form of defense, contradictory story lines, a plethora of detail, together with


436 much stumbling and uncertainty prevails, resulting in marked incoherence. Individuals classified as unresolved fail to contain or “resolve” indications of segregated systems that emerge in the stories (e.g., fear, harm, death), following the nomenclature in the field (see George and West, 2011/this issue). The characters are unable to make reference to any form of protection, including internalization, the capacity to take meaningful action, or consistently help, or at least ask assistance from others. The AAP psychometric properties have been examined (see George and West, 2011/this issue). Interjudge reliability for secure versus insecure classifications was .93 (κ = .73, p < .001); interjudge reliability for the four major attachment groups was .86 (κ = .79, p < .001). Test–retest reliability was tested after 3 months in a sample of 69 participants. Fifty-eight (84%) were classified in the same main categories (κ = .78, p < .001). Stability for the secure classification group was 82%. Stability for the insecure classification group was 96% for dismissing, 62% for preoccupied, and 80% for unresolved. Interjudge reliability for AAP categories has not been evaluated. Because the AAI (George et al., 1984, 1985, 1996) is an instrument with much research and proven validity, convergent validity with AAP was particularly important to assess. Convergent validity between AAP and AAI classifications have been established (George & West, 2001). AAP–AAI convergence for secure versus insecure classifications was .95 (κ = .75, p < .001); convergence for the four major attachment groups was .89 (κ = .84, p < .001; West & George, 2002). Discriminant validity for the AAP for verbal intelligence and social desirability were examined (see George & West, 2011/this issue).

Rorschach Comprehensive System The Rorschach Inkblot Test (Rorschach, 1921) was administered, scored, and interpreted according to Exner’s Comprehensive System (CS; Exner, 1991, 1993; Exner & Weiner, 1995). In the CS, the Rorschach test is essentially a behavioral problem-solving task (Viglione, 1999) and a performance-based personality test (Meyer et al., 1998). Recent meta-analyses have documented its validity (Grønnerød, 2004). In the literature, the incremental validity of the CS was also assessed and discussed (e.g., Hartmann, Sunde, Kristensen, & Martinussen, 2003; Hartmann, Wang, Berg, & Saether, 2003; Janson & Stattin, 2003). Reliability, as interrater reliability (Acklin, McDowell, Verschell, & Chan, 2000; Meyer et al., 2002; Meyer, Mihura, & Smith, 2005) and as temporal stability of CS variables, was also documented (Grønnerød, 2004). The CS interpretation is based on clusters that can yield systematic and comprehensive information concerning psychological functioning including affect, controls, interpersonal relations, self-image information processing, reality testing, and thinking, and is, therefore, a useful psychodiagnostic instrument in treatment planning in a multimethod assessment approach. Questionnaires and Interviews The SCL–90–R (Derogatis & Lazarus, 1994), a 90-item, brief, multidimensional self-report checklist, was used to screen psychological problems and symptoms of psychopathology. Nine primary symptom dimensions, as well as symptom intensity were measured: somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety,

LIS, MAZZESCHI, DI RISO, SALCUNI paranoid ideation, and psychoticism. A Global Severity Index is also measured. Another questionnaire was selected for attaining specific information important to anorexia nervosa, the BUT (Cuzzolaro et al., 2006), a 71-item self-report questionnaire in two parts. BUT–A measures five dimensions: weight phobia, body image concerns, avoidance, compulsive self-monitoring, and detachment and estrangement feelings toward one’s own body (depersonalization). BUT–B looks at specific worries about particular body parts or functions. We also administered the Operationalized Psychodynamic Diagnosis (OPD; OPD Task Force, 2001), which was conducted to gain information about meaningful life events and perception of the illness. A clinical interview is developed to propose operationalized clinical diagnostic guidelines; it is audio recorded and transcribed for scoring. Five diagnostic axes are defined: Axis I, experience of illness and prerequisites of treatment; Axis II, relational issues; Axis III, conflict; Axis IV, structure; and Axis V, syndrome diagnostics according to the International Classification of Diseases (10th ed. [ICD–10]; World Health Organization, 1992). For the aim of this article, only Axis I and Axis IV were defined.

RESULTS AAP Picture System Emily’s AAP responses are presented first, followed by a description of each story’s unique features of attachment content and defense interpreted using the AAP coding system. We then move to a general discussion of the AAP classification. Emily was judged as unresolved on the AAP. The following discussion demonstrates that Emily becomes dysregulated and disorganized in response to several of the AAP scenes, however she is able to reorganize and contain her fears in response to all the stimuli except those that she associated with illness (ambulance, cemetery). Dyadic Pictures: The dyadic picture stimuli portray attachment–caregiving dyads. The responses to the dyadic stimuli demonstrate Emily’s representation of the self and other in attachment situations when attachment figures are present and accessible. The responses to these pictures allow us to see if Emily is able to make use of attachment figures to quell the attachment anxiety aroused in the scenes depicted in the cards. Departure: “Luggage, holidays . . . having a break. What may have happened before? The rush of everyday life makes them decide to have a holiday together. And what is happening? Looking for peace . . . to spend some time in peace, to return to everyday life, maybe more calm. Anything else? No.” In departure, where generally a couple is described, Emily is unable to specify the identities of the characters and their relationship is defined only by its function (“holiday together”). The response depicts vague togetherness. So Emily fails to portray a specific couple in a warm relationship as most secure people do. Emily reduces her attachment needs when she builds the image of “everyday life” to which she aspires. Within this scene, she simply glosses over the problem (“Looking for peace . . . to spend some time in peace, to return to everyday life, maybe more calm”), a form of cognitive disconnection.


ATTACHMENT, ASSESSMENT, AND INTERVENTION Bed: “A child with her mother. The child asks the mother for a hug . . . she is ready to hug . . . And what happened before? Maybe the child had a nightmare and his mum, hearing him crying, went to comfort him. And what happened next? After the hug, the mum calms down the child, who goes back to sleep peacefully. What are their feelings or thoughts? Love. Anything else? No.” Emily tells a very good story from an attachment point of view. The goal of attachment—proximity and care by the attachment figure—is achieved through mother–child interactive synchrony. The child signals her attachment need directly to her mother; her mother responds promptly and contingently. This response also reveals Emily’s segregated systems, “nightmare,” a form of danger in the AAP coding. This story depicts Emily’s experience of her caregiver in a “warm, intimate, and continuous relationship with her mother (or permanent mother substitute) in which both find satisfaction and enjoyment” (Bowlby, 1951, p. 13, as quoted by Bretherton, 1992). Only when the attachment relationship attains this level of synchrony can Emily truly go back to sleep. Ambulance: “Mother with a sick child. He is hurt and they are waiting for doctors and paramedics and the ambulance that will take him to hospital. Feeling and thinking, let me see . . . The mother is anxious about her child’s health . . . the child is not aware of how sick he is, of what . . . of his pain. Anything else? No.” The prototypic ambulance response is a story that describes two characters (a woman and a child) engaged in a range of themes related to a third character lying on a stretcher. These might include the arrival of the ambulance in response to an illness or death of the child’s relation or the adult’s neighbor, or the woman–child dyad witnessing the ambulance arrive while they wait in a hospital for the child or another family member to be treated. To represent very severe forms of sickness and death, as sketched by the character lying on a stretcher, is too hard for Emily. She only identifies two characters, the adult (mother) and the child (self). Emily does not create a response that includes seeking or receiving comfort from the attachment figure. The mother and child “wait” for help in attending to their attachment tension (“hurt”). The mother is further disconnected from the situation by her preoccupation (“anxiety”), a response to confusion that distracts her from providing care or comfort for her child. The potential care and comfort shifts from the attachment figure to professionals. Cognitive disconnection predominates in the response, revealing Emily’s overall view of sickness as being filled with uncertain and anxiety. She also uses deactivation that reduces tension by appealing to professional intellect and skill. The story ending is Emily’s description of being disconnected from the (“unaware”) traumatic and threatening quality of her illness (“pain”). The story is left unresolved. The boy remains in pain as the help that the mother and child are anticipating has not yet arrived. Essentially, Emily’s story about her illness is overwhelming and unfinished. The story being unresolved is an indication of her illness as overwhelming. Alone Pictures. These pictures portray stressful situations in the absence of visible (i.e., perceptually accessible) attachment figures. The alone responses tell us whether Emily’s inner representation of self demonstrates her internal resources, the potential availability and responsiveness of attachment figures,

437 and her desire for interpersonal relationships, including those that are not attachment relationships.

Window: “I see an empty house and a girl who is looking outside hoping to find some company. What do you think led up to that scene? I do not know . . . maybe she is thinking about the empty house. What is she thinking or feeling? The child feels alone, there is no one . . . and she is looking for someone . . . a face . . . a figure from outside, something that will give a sense of life. What do you think will happen next? She sees life outside, maybe she decides to go out.” The window is the first stimulus in the picture set. Typical AAP responses to this scene describe a girl engaged in a home-related scenario, such as figuring out a play activity or waiting for parents to come home. Rather, Emily is immediately threatened by the girl’s solitude. Her response reveals that she is primarily overcome by aloneness, the “empty house,” “thinking about the empty house” (segregated system; Bowlby, 1980). She feels empty and alone in her own house and seeks some sign of life from outside. The description of seeking a “face” or “figure” is an image in the AAP that connotes Emily’s inability to appeal to a safe and specific attachment figure. Consciousness is flooded by segregated feelings of emptiness and isolation (“empty house”) and the desperation of searching for a person who “will give a sense of life.” Emily demonstrates a capacity for reorganization through the girl’s ability to make a conscious decision to take action and go out. It is not a specific solution in that Emily does not describe where the place is or what she does there, but this representational action designates a shift in the mindset that prevents her from becoming completely disorganized. Bench: “It looks like a prison . . . someone is sitting alone on a bench and crying. What is the person thinking or feeling? Feeling lost. What do you think led to that scene? She has done something that she was not supposed to, and so she was locked up . . . she was punished . . . she is sorry for what she did. What do you think will happen next? Once she has made amends for all the things she has done she will get out of this prison. Anything else? I can see myself here a little bit.” As in window, the loneliness of the bench picture again triggers segregated feelings of emptiness, isolation (“prison”), and danger (“lost”). She can only describe the segregated system; she is unable to envisage being connected to attachment figures or any other human beings at this moment. Again, as with the window response, there are no signs of life. Emily becomes so absorbed in her aloneness in this response to the bench stimulus that she does not even create a character to represent the self (the only referent for the depicted character is “she”). Emily’s story suggests her attempts to deactivate or reduce the intensity of her attachment needs. She has tried to create distance in relationships and shifts attention sufficiently away from emotion so that the self can remain neutral and strong in the face of threat. However, sometimes her attempts to deactivate attachment backfire, so to speak, and instead she is left frightened and alone. The solution to punishment is to make amends, although Emily cannot specify the wrongdoing that created the situation in the first place. She is involved in a weak attempt to make amends. So Emily can envisage herself, to a limited extent, moving forward using her internalized secure base capacities,

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capacities that demonstrate a weak potential for reintegration and security.

Cemetery: “A man in a cemetery. He is crying at his father’s grave . . . great pain for the person who died. What do you think led up to that scene? The pain of a major illness, but in the end . . . freedom, because . . . an incurable illness and so at the end death. What do you think will happen next? Freedom from pain. What is the person thinking or feeling? Loneliness, because in any case the person is no longer there. Anything else. No.” Unlike the absence of other human beings in Emily’s previous alone responses, Emily specifies the identities of the characters in this story and clearly reveals the intensity of the traumatic pain associated with the loss. These emotions are extremely overwhelming for Emily. She is unable to depict the man as engaged in any form of specific thought or action, or as being rescued. The fragile and very poor organization she has been able to maintain in response to the alone stimuli falls apart. She describes pain from the perspective of both members of the attachment dyad. The survivor lives in pain “for the person who is no longer there” and the deceased has had to live with the pain of “incurable illness.” Corner: “A child who is avoiding something, who does not look at anything . . . like he is trying to reject someone, maybe an adult. He bows his head and looks away because he does not want to look, to listen . . . What was happening before? Maybe someone has done something to him that he was not supposed to or told him something he was not supposed to tell him and so it is like he is trying to avoid . . . does not want to be hurt. And later what could happen? Maybe he will decide to leave the corner and look for someone who could support him. What could he be feeling or thinking? He is trying to defend, to protect himself.” Emily clearly reveals that adults telling her what to do, and what not to do, is harmful for her (“hurt”). However, she describes a child in an effort to protect the self from the hurtful appraisals of an adult. Emily views rejection, another form of deactivating defenses in the AAP, as the way to protect herself. She can push others away and, by doing this, she gets a sense of confidence that she can seek help from someone else. It is a weak sense of confidence, however, because Emily cannot envisage who this “someone” providing support could be. Attachment Classification Discussion. Emily’s unresolved pattern of attachment demonstrates that she cannot integrate, consciously evaluate, or reorganize the pain and isolation that she feels in relation to her illness and her attachment figures’ inability to protect her from this distress. Although Emily draws on deactivation and cognitive disconnection to manage attachment disorganization, she fails in keeping her attachment regulated. Segregated systems material is highlighted in response to each AAP picture stimulus with the exception of departure. The window and bench stories show images of the self in an empty and isolating structure, which reveals the loneliness and fear Emily experiences in the eating disorder clinic. Embedded in Emily’s unresolved status is a glimmer of hope, so to speak. She portrays a sensitive and responsive mother figure in response to the bed scene and demonstrates an attempt to repair and integrate her feelings and experiences so she can move forward in response to the bench scene. These are coded in the AAP as integrated synchrony and haven of safety, respectively. However,

LIS, MAZZESCHI, DI RISO, SALCUNI placed in the context of the entire transcript, Emily’s responses demonstrate that her representational capacity for security is fragile and fractured. As mentioned earlier, organizing defenses might not prevent Emily from becoming disorganized and dysregulated by her pervasive fears. When confronted with the stimuli associated with illness and its consequence—death—Emily’s defensive structure broke down completely. No forms of organized defensive exclusion could prevent images of succumbing to her illness and death’s release.

Rorschach Comprehensive System The Structural Summary is reported in Table 1. Emily gives a low number of responses (only 17), has a high Lambda (1.83), and her EA of 1.5 is suspiciously low. Such a short, form-dominated, low EA record could be attributed to an engagement with the task that is not sufficient to produce a valid record. However, Emily seemed to be quite involved during the administration of the measures. So, the very short and economic record might reflect the impact of a transient crisis and thus fail to fully represent her usual resources. In cases with high Lambda and such a low EA, particularly with low R, Exner (2000) advises against interpreting the Control cluster, because of the likelihood that it is unreliable, not to mention the strong possibility of a transient psychological crisis (Exner, 2000). Positive key variables were CDI>3 and EA Low (EA = 1.5). The warning about a valid interpretation of the Control cluster led to the following interpretative search strategy: Affect → Self-Perception → Interpersonal Perception → Processing → Mediation → Ideation. Affect. Emily showed very few affects (FC:CF + C = 1:0). This maladaptive emotional block put her at risk of adjustment difficulties. Further, she exerted severe control over expressing feelings (SumC’:WSumC = 4:0.5). As a consequence, she did not become easily involved in affectively charged situations (Afr = 0.42). Self-Perception. Emily showed low levels of selfconfidence and self-esteem (3r + (2)/R = 0.29). She had limited introspective ability (FD = 0) and was unable to acknowledge the impact she had on other people. She had a limited capacity to examine herself in a critical way and to modify her behavior accordingly. Moreover, she is unable to represent herself realistically (H:(H) + Hd + (Hd) = 0:3). Interpersonal Perception. Emily showed a limited ability to manage interpersonal relationships in a suitable manner (CDI = 4). She was not able to create a consistent and realistic idea about others (Pure H = 0; SumH = 3) and was, therefore, not well-adapted in interpersonal relationships (GHR:PHR = 1:2). She was not able to consider relationships as meaningful aspects of her experiences, showing little interest in engaging in collaborative or competitive relationships with other people. She was therefore considered by others as distant (AG = 0 and COP = 0; T = 0). Processing. Emily presented a simplistic way of looking at the world and had difficulty recognizing complex relationships between events (Zf = 9, Dv = 1). Following traditional interpretation, she showed a strong achievement orientation but is

ATTACHMENT, ASSESSMENT, AND INTERVENTION

439

TABLE 1.—Emily: Rorschach Structural Summary. DETERMINANTS


LOCATION FEATURES

BLENDS

Zf ZSum ZEst

=9 = 26.5 = 27.5

W (Wv D W+D Dd S

=8 = 0) =6 = 14 =3 =2

DQ + o v/+ v

SINGLE

YF.FC’ FC’.m

(FQ− ) (1) (4) (0) (1)

=4 = 12 =0 =1

FORM QUALITY FQx =0 =5 =6 =6 =0

+ o u − none

MQual 0 0 0 1 0

W+D 0 5 5 4 0

CONTENTS

M FM m FC CF C Cn FC’ C’F C’

= = = = = = = = = =

1 0 0 1 0 0 0 2 0 0

FT TF T FV VF V FY YF Y Fr rF FD F

= = = = = = = = = = = = =

0 0 0 0 0 0 0 0 0 0 0 0 11

(2)

=

5

H (H) Hd (Hd) Hx A (A) Ad (Ad) An Art

= = = = = = = = = = =

0 0 2 1 0 7 0 2 0 0 0

Ay Bl Bt Cg Cl Ex Fd Fi Ge Hh Ls Na Sc Sx Xy Idio

= = = = = = = = = = = = = = = =

0 0 2 0 0 0 0 0 0 1 0 1 2 0 1 1

S-CONSTELLATION FV+VF+V+FD > 2 Col-Shd Blends > 0 Ego < .31 or > .44 MOR > 3 Zd > ±3.5 es > EA CF + C > FC X+% < .70 S>3 P < 3 or > 8 Pure H < 2 R < 17 TOTAL SPECIAL SCORES Lv-1 DV =0 x1 INC =0 x2 DR =0 x3 FAB =0 x4 ALOG =0 x5 CON =0 x7 Raw Sum6 =0 Wgtd Sum6 =0 √ √ √ √ √ 5

AB AG COP CP

=0 =0 =0 =0

Lv-2 0 x2 0 x4 0 x6 0 x7

=1 =2 =0 =0 =0

GHR PHR MOR PER PSV

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RATIOS, PERCENTAGES, AND DERIVATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CORE SECTION AFFECT INTERPERSONAL R EB eb

= =

= 17

L

1:0.5 1:5

EA es Adj es

=0 =1

FM m

=

2

= 1.5 =6 =6

SumC’ SumV

IDEATION a:p = 1:1 Ma:Mp = 0:1 2AB+Art+Ay = 0 MOR =0

PTI

= 1.83

=4 =0

Sum6 Lv-2 WSum6 MMnone

DEPI = 4

EBPer D Adj D

= N/A = −1 = −1

SumT SumY

=0 =0

FC:CF+C Pure C SumC’:WSumC Afr S Blends/R CP

MEDIATION XA% = 0.65 WDA% = 0.71 X-% = 0.35 S=0 P =2 X+% = 0.29 Xu% = 0.35

=0 =0 =0 =1 =0

√

CDI = 4

unable to balance the resources at her disposal with her goals (W:M = 8:1).

Mediation. Emily manifested an impairment in reality testing (XA% = .65 and WDA% = .71), even in simple and welldefined situations in her life. She was unable to perceive environment, people, and events in a conventional way (P = 2).

= 1:0 =0 = 4:0.5 = 0.42 =2 = 2:17 =0

COP = 0 GHR:PHR a:p Food SumT Human Cont PureH PER Isolation Index PROCESSING Zf =9 W:D:Dd = 8 :6 :3 W:M = 8:1 Zd = −1.0 PSV =0 DQ+ =4 DQv =1

S-CON = 5

AG = 0 = 1:2 = 1:1 =0 =0 =3 =0 =0 = 0.24 SELF PERCEPTION 3r+(2)/R Fr+rF SumV FD An+Xy MOR H:(H)+Hd+(Hd)

HVI

= No

= 0.29 =0 =0 =0 =1 =0 = 0:3

OBS = No

Ideation. Emily was able to think logically and coherently (Raw Sum6 = 0; Wgtd Sum6 = 0). However, when she was thinking of people and their actions, or maybe when affective material interfered, her thinking could become slightly peculiar (M– = 1). Questionnaires and the Clinical Interview SCL–90–R. The highest significant scores were for depression, anxiety, and interpersonal sensitivity. Emily felt sad and

440 uneasy in interpersonal relationships. The Global Score Index was mild.


BUT. Emily’s BUT–A scores were significantly higher than normative nonpatient scores for all five dimensions (Cuzzolaro et al., 2006). Almost all items of the BUT–B were scored at a pathological level (3–5) showing how Emily consciously recognized how she was ashamed of her body and body parts (e.g., thighs and stomach), how she hated her body, could not look at her image in the mirror, and would like to have a different and very thin body. Clinical Interview. Emily appeared to be a very shy and reserved teenager during the OPD clinical interview and assessment. She looked younger than her real age and seemed to be slightly stressed. She had attended a linguistic high school with no success. Her interview demonstrated that she had some difficulty in expressing her feelings, problems, and internal world to other people. However, she seemed to be motivated to undergo the clinical interview. Social contact with peers was poor or nonexistent and she had never dated or had a sexual or romantic relationship. She reported that sometimes she preferred to be silent when surrounded by other people. She appeared to direct all her energies to the control of her body. The disturbance was completely egosyntonic and she had no awareness of the real severity of her condition. She said she accepted being admitted to the clinic because her parents were worried, but there was no real problem. Her mother seemed to be very worried although the family tended to minimize Emily’s problems and refused to fully accept her illness until they could no longer avoid recognizing her physical situation. The OPD classification of Axis IV showed a low integrated personality structure. Integration of the Assessment Tools for Emily’s Treatment Plan In short, the assessment of this young patient produced a psychologically bleak picture regarding survival and change. The externalizing symptoms were severe and ego syntonic as she did not seem to be aware of her condition. There is a connection between her not seeming to be aware of her condition, her inadequate appreciation of her difficulties, and the segregated systems associated with her unresolved attachment status. The symptoms were highlighted also in the CS data. The AAP structure suggested that deactivating defenses and segregated systems kept Emily from being aware of the intense disorganizing fear she experienced in association with her illness. The formulation of therapeutic goals on the basis of the various tools administered in the assessment phase according to Bihlar and Carlsson’s (2000) goal categories, led to the following clinical framework for a treatment plan. Symptoms. The most critical element of any treatment plan in working with anorexia (particularly in this case where the patient weighs just 70 lbs. and is an inpatient) is weight gain. It is crucially important to include medical stabilization and restoration of normal eating in the treatment plan. Generally, this is also accomplished through consultation with a dietician. As Emily gains weight, her mental clarity, emotional vitality, interest in the world, and motivation will improve substantially. There is the possibility that some attachment-related responses in the AAP might change as well. For example, the child in

LIS, MAZZESCHI, DI RISO, SALCUNI ambulance could become aware of how sick he is. According to the SCL–90–R, her minimization of her possible symptoms has led to an unrealistically low Global Index Score. The picture became worse when the results of the BUT were examined. She showed a very distorted and unacceptable view of herself, with an impossible wish to be thin. The Rorschach confirmed a low self-examining capacity and impairment in behavior appropriate to the situation. Emily’s attachment classification was unresolved and her main organizing defensive process was deactivation. The goal of reducing symptoms appeared more and more difficult to achieve because of the deactivating and segregating tendencies that prevent subjective awareness of her needs. There might be some hope of managing the physical and psychological symptoms if a curative environment and a secure therapist were able to help Emily understand how her treatment could help her emotionally as well as physically. One of the crucial aims was to help her exit the “empty place” in which she was locked, afraid, alone, and helpless.

Rehabilitation. Emily appeared to put all her energies into the control of her body. She needed help to start attending school again, but also to be able to face daily tasks at the clinic and later at home. An explanation for these difficulties can be found in the AAP. Emily had impaired ability to get involved in concrete actions to deal with her experiences. Her lack of connectedness, her inability in the stories to describe specific connections with friends, much less people in general, made it very difficult to achieve this goal. In the absence of agency, connectedness, and limited synchrony, Emily’s inabilities worsened when she was scared or traumatized. The AAP also demonstrated Emily’s sensitivity to traumatization due to the prevalence of traumatic levels of fear. Life Goals. It is not possible to set any kind of general life goal in the present situation. From the AAP it appeared that Emily was seeking increased quality of life, represented by seeking “signs of life” in her environment. What is not clear, however, is the degree to which Emily would cooperate with suggestions related to life goals if those suggestions were experienced as too intense or threatening. Life goals might need to begin with how to foster a more enduring sense of security, a capacity that is visible in at least a limited way in Emily’s AAP. Control Capacity. The goal was to increase the ability to maintain psychological control in demanding or stressful situations, to reduce exaggerated control, and to increase accessibility to more useful and flexible psychological defenses. The results of the clinical interview and the AAP converged in their findings that Emily was fragile and had a minimal capacity for maintaining psychological control. The OPD showed very primitive defenses such as denial and idealization. In the AAP, her meaningful psychological material seemed to be bottled up. Defensive mechanisms were strong and rigid and did not allow her to integrate painful experiences even if they were to percolate to the surface. She exercised exaggerated psychological control over threatening material, such as situations that recalled danger and isolation. Moreover the AAP showed a very limited ability to cope with stressful situations. The very short and economic CS record reflected the impact of a transient crisis and thus failed to fully represent her ordinary resources. In this state of psychological crisis Emily revealed severely impaired adaptive

ATTACHMENT, ASSESSMENT, AND INTERVENTION


capacities. She was likely to have difficulty in managing even ordinary ideational and emotional stress in everyday life without becoming unduly upset by them. In treatment, she would benefit most not from efforts to reduce the stressors in her life, but instead from help in improving her coping skills and in learning consistent strategies to manage her painful internalized feelings, expressed both in the Rorschach and in the AAP.

Affects. This reflects the capacity to contain, handle, and express affects. During the interview, Emily’s affective life appeared completely flat or absent. She employed defensive maneuvers to blunt the impact of her traumatic feelings or to conceal their existence. In the AAP, this affective state is consistent with the rigid attempt to neutralize affect associated with deactivating defenses. The CS also demonstrated that she was unable to experience feelings and emotions. Her emotions were completely bottled up, as the presence of segregated system along the AAP stories demonstrated. We can equate the CS “emotional block” with the ways that Emily separates out her dangerous affects. She seemed only partly aware of having such feelings (SCL–90–R) and they might be connected with the traumatic unresolved experiences triggered in the AAP. Following Bowlby (1988), the clinician should provide Emily with a “secure attachment figure” to help her explore her blocked emotions. Self-Perception. Self-perception includes changes pertaining to self-definition, improving self-esteem, and having a more realistic perception of the self. The AAP showed how selfdefinition has never developed in a stable and integrated way in Emily. In some AAP stories, she did not give a specific identity to the characters (“someone,” “they”). The Rorschach also showed that she was unable to be adequately involved in herself, that she likely had a low judgment of her personal worth and views herself unfavorably. The clinical interview confirmed this distorted perception of the self. A “secure attachment figure” (Bowlby, 1988) could help Emily become connected with herself and to reach a more consistent and integrated way to represent herself. Changing her self-definition, improving selfesteem, and having a more realistic perception of the self would be an extremely important goal, but a very difficult one to attain because Emily appears to be very resistant to this kind of change. Interpersonal Relations. Emily displayed many liabilities in interpersonal relationships in real life and in her representational world (AAP and Rorschach). In the AAP, although she did reveal a glimmer of a capacity for attachment security (bed), specific human relationships (mother and child) that could provide real care and comfort were almost entirely absent from her responses. On the Rorschach she also did not show evidence of pure human responses and collaborative or competitive relational representations. It will require a great effort in psychotherapy to modify this very sad picture. Mediation/Ideation. The goal was to increase the capacity to evaluate one’s own thoughts and develop the capacity to interpret reality more realistically. The clinical interview and the BUT highlighted how Emily was unable to look realistically at her anorexic symptoms and her body. She represented herself as capable of expressing attachment needs clearly, and as alone and desperate to find companionship and potential attachment figures to reach out to. However, overall, her AAP stories

441 revealed that she was unable to look realistically at the self, people, relationships, and care. The Rorschach supported the inference that she is unable to interpret her experience realistically. Luckily, she was able to think logically and coherently, which could be helpful because the therapist could rely on this single strength. Emily’s treatment could be helped by assistance in recounting attachment stories in a more realistic way, moving toward stories that maintain consistency, affect regulation, and achieving attachment needs. Some therapists have used the AAP picture stimuli to facilitate this task (see Finn, 2011/this issue).

Insight. Emily did not demonstrate any introspective or metacognitive capacity in any of the tools administered. This kind of goal could not be taken into account in a possible intervention and expressive therapy should not be the elective treatment. Theoretical Formulations. These were ormulations about Emily’s illness in relation to her family. Anorexia nervosa remains one of the few mental disorders widely attributed to poor parenting. Bowlby (1973) proposed a model in which eating disorders seemed to be related to specific family attitudes. Also, much earlier literature claimed that family relational factors were connected to the onset of anorexia nervosa (Bruch, 1973, 1978, 1982; Bulik et al., 2006; Farber, 2002; Minuchin, Rosman, & Baker, 1978). Nevertheless, no such causal connection has been established by empirical research. Given the controversial and inconclusive status of the connections among early parenting, environment, and anorexia symptoms, this article takes no position on these matters. Let it suffice that relationships in families of patients with anorexia nervosa certainly become distorted as a result of the illness. Family involvement is extremely important in the treatment of anorexia nervosa according to the Maudsley model of treatment (Le Grange, Lock, Loeb, & Nicholls, 2010), and could well be crucial in renourishing the patient (Eisler, 1995). Attachment patterns can be described as reactive or secondary to the development of anorexia nervosa, and are not necessarily etiological. In an attachment theory frame, the authors support the role of parenting. Therefore, measuring attachment could well make an important contribution to the treatment of this young woman, and to the literature as well. Emily’s attachment figures in the AAP stories appeared to be very contradictory. Emily’s father was described as overcontrolling. Is he the attachment figure to which Emily refers in corner? Her mother could be sensitive yet also preoccupied and unresponsive. Emily’s story about her illness is dysregulating and unfinished, and the AAP findings make suggestions for how to move this story forward. Resolving some of the attachment issues noted in the assessment hold promise of utility in working with this young woman and her family concerning how they can cooperate and work together in helping Emily to restore her weight. We can see from Emily’s case that although her underlying attachment patterns might not be strictly the cause of her eating disorder, they are in any event likely to interfere with treating it. Therapeutic Tasks. Therapeutic tasks are formulations about tasks and psychotherapeutic means, which are natural elements in psychotherapy. Emily’s use of a secure attachment figure in psychotherapy will initially be useful, primarily in helping her form alliances with caregivers and family who will help her eat. The resolution of the anorexia nervosa itself will take

LIS, MAZZESCHI, DI RISO, SALCUNI


442 place through eating, and it is when she is no longer starving that there is more likely to be an improvement in her affect regulation and mentalization processes, which could set the stage for further psychotherapeutic work. However, we hypothesize that she will be resistant and unwilling to cooperate in therapy. Emily’s resistance in the therapeutic setting was her expression of distancing defensive deactivation (Dozier, Lomax, Tyrrell, & Lee, 2001). As it happens in corner, the therapist who is trying to reach her will find her trying to “avoid” and to “reject.” Working alliance is connected to the concept of a “secure base” that the clinician can provide. Following attachment theory, the working alliance is built on helping to break away some defensive postures and fortify others so that the therapist can ultimately help the patient integrate experience and affect and “mourn” (West, Rose, & Sheldon-Keller, 1995). It would not be so easy to build such a working alliance. The therapist who is trying to help her could represent, above all at the beginning of the treatment, just a vague someone who will give her “some company” or “someone, a face, a figure from outside” as expressed in window. However, through the new and “intimate therapeutic relationship,” the therapist would become for Emily a figure “who comforts” or “who calms down” as portrayed in the bed response. Emily might then achieve skills in problem solving and enjoyment of life.

Theoretical Goals. Emily looked younger than her age and did not talk about sexuality and intimate relationships. We could suppose that she had not reached a true adolescent process. According to attachment theory, attachment relationships foster integration of attachment with relationships in peer behavioral systems in adolescence and adulthood (Allen, 2008; George & Solomon, 2008; George & West, in press; West & George, 1999). These include friendships and romantic relationships. The only relationships Emily could specifically identify in her stories were attachment relationships—those between parents and children. Although in departure she seemed to talk about friends or lovers, Emily was not able to clearly identify them. She was not able to represent a self in search of friends or romance. She probably needs to face this important passage of development, beginning with friendships, as they are thought to be one of the first extensions in childhood of the parent–child attachment (Allen, 2008). CONCLUSIONS The specific aim of this article was to demonstrate to clinicians how a recently developed tool for assessing patterns of attachment, the AAP (George & West, 2001), could be useful when used in a multimethod personality assessment and treatment plan. We presented a case of an adolescent anorexic girl to produce a more detailed picture of how attachment information using the AAP contributes to completing the assessment battery. This article does not presume that the eating disorder is necessarily a direct outgrowth of attachment pathology. This article also does not argue that attachment patterns are necessarily etiological for the onset of anorexia nervosa; they might well be reactive or secondary. However, assessing attachment means more than determining a patient’s attachment classification status, which in Emily’s case was unresolved. Indeed, it is not unusual for individuals in clinical samples (inpatient and outpatient) to be found to have an unresolved attachment (Dozier, Stovall-McClough,

& Albus, 2008). The key to understanding how to add the results of attachment assessment to a multimethod approach is to take into consideration the attachment measure to elucidate the patient’s representational and defensive patterns related to attachment activation in Bowlby (1980) terms. These patterns were most clearly elucidated in this case by the AAP. The AAP made it possible to understand how Emily’s unique representational patterns in response to a standardized set of picture stimuli of attachment events blocked her conscious awareness of fear and pain and maintained a set of fairly sturdy defenses against seeking help or letting others provide care. The AAP also allowed the clinicians to reflect on what kind of therapeutic alliance she would be able to form with a therapist. We hope that from the detailed description of the case and these comments, clinicians might understand how attachment is not only a categorical classification, but a dynamic tool that can provide information about personality functioning, above all when the AAP has been used. In Padova, our team works clinically with college students, children, and adolescents, and the case presented is an example of the way in which the AAP is used in the assessment and treatment plan of college students. We are now carrying out a new project with college students, children, and adolescents about collaborative assessment. The AAP has often been used in this project and, so far, has proven to be very useful (Lis et al., 2008).

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