How Eating Disorders Impact on Relationships

When anorexia nervosa or bulimia nervosa patients are married or live together with a partner unmarried, the question arises as to what impact an eating disorder has on the relationship with a partner or, alternatively, how an intimate relationship with a partner influences the course of an eating disorder.

Despite valuable implications, the marital relationships of adult eating-disordered patients have not received much attention in the form of empirical research. One of the major impressions emphasized in clinical literature is that married eating disordered patients and their partners often report a significant degree of dissatisfaction with their relationships (Van den Broucke & Vandereycken, 1988).

Marital intimacy is one aspect of a relationship which may be conceived both as a process which includes empathy, (e.g., a characteristic way of relating of two partners), and as a state, (e.g., a relatively stable, structural quality of a relationship which emerges from this process) (Waring, 1988). Van den Broucke, Vandereycken, & Vertommen (1995) see intimacy as a quality of a personal relationship at a certain point in time primarily referring to a relational phenomenon, (e.g., the degree of connectedness or interdependence between two partners). As such it includes affective, cognitive and behavioral aspects. These three types of interdependence are reflected in the couples' emotional closeness, empathy and commitment, the validation of each other's ideas and values, and the implicit or explicit consensus about the rules which guide their interactions (Van den Broucke et al, 1988). No Iframes

Additionally Van den Broucke, Vandereycken, & Vertommen (1995) suggest that there are two additional levels of intimacy, individual and situational. On an individual level, intimacy implies two aspects, one being authenticity, or the ability to be oneself in the relationship with the partner, and openness, or the readiness to share ideas and feelings with the partner. The situational level entails an aspect of exclusiveness: As the partners' individual privacy decreases with the enhancement of their intimacy, the dyadic privacy is likely to increase. Communication difficulties and the lack of openness in eating disordered patients' marriages were found and considered to be a serious relational deficiency, which may represent an important obstacle to the growth and enhancement of their marital intimacy. The intimacy deficiency of these patients' marriages does not necessarily imply that this deficiency is the cause of the eating disorder but probably more accurately is described as a circular enigma (Van den Broucke et al, 1995).

With empathy holding a key position in the construct of intimacy, Tangney's (1991) research discovering a positive correlation between proneness to guilt and empathetic responsiveness but inversely related to the tendency to experience shame, may provide some insight into the relational difficulties described by Van den Broucke, Vandereycken, & Vertommen (1995). Bateson (1990) defined empathy as including feelings of sympathy and concern, but distinguished empathy/sympathy from personal distress, the latter representing an observer's own feelings of distress in response to a distressed other. This other-oriented empathic concern, not self-oriented personal distress, has been linked to altruistic helping behavior (Bateson, 1988). Other-oriented empathy is generally viewed as the good moral affective capacity or experience because it is presumed to foster warm, close interpersonal relationships, to facilitate altruistic and prosocial behavior, and to inhibit interpersonal aggression (Bateson, 1990). Shame, an ugly feeling, draws the focus away from the distressed other, back to the self. This preoccupation with the self is inconsistent with the other-orientated nature of empathy. When faced with a distressed other, shame-prone individuals may be particularly likely to respond with a personal distress reaction, in lieu of a true empathetic response. The acute pain of shame may motivate a variety of intrapersonal and interpersonal processes that are incompatible with a continued empathic connection. Shame-prone individuals have a tendency to externalize cause or blame, as a defense maneuver against the overwhelming pain of the shame experience, in addition to making internal, global shame-type responses (Tangney, 1990; Tangney, 1991; Tangney, Wagner, Fletcher, & Gramzow, 1992).

While shame involves the self's negative evaluation of the entire self, guilt involves the self's negative evaluation of specific behaviors. Guilt's consequent motivation and behavior tends to be oriented toward reparative action. Guilt seems less likely to motivate the defensive maneuvers, antithetical to empathy, that are frequently associated with shame. Guilt-prone individuals are clearly not disposed to blame external factors or other people for negative events allowing room for empathetic responsiveness (Tangney, 1990, Tangney, 1991; Tangney et al, 1992). Tangney (1991) discovered that individuals who are generally empathic are also prone to feelings of guilt, exclusive of shame. The perspective-taking component of mature empathy requires the ability to make a clear differentiation between self and other. Guilt requires making a clear distinction between self and behavior, an ability to see behaviors as related but somewhat distinct from the self. Both guilt and empathy hinge on a capacity for differentiation, a more mature level of psychological development similar to such constructs as psychological differentiation, ego development, and cognitive complexity (Bateson, 1990; Tangney, 1991; Tangney et al, 1992). Shame-prone individuals may have difficulty maintaining an other-oriented empathic response, and instead may drift into a more self-focused personal distress reaction. They are likely to experience the resonant pain of personal distress as well as the pain of shame for "being the kind of person who would inflict such harm" (Bateson, 1990; Tangney, 1991). This wash of negative affect may be problematic as Berkowitz (1989) has demonstrated, negative affect in general can foster angry, hostile feelings and subsequent aggressive responses.

Consistent links have been found between proneness to shame and anger (Berkowitz, 1989; Tangney et al, 1992). Such anger may be fueled not only by the pain of shame itself, but also by the discomfort inherent in personal distress reaction to distressed others. The unpleasant interpersonal exchange may be so overwhelming that it may motivate a variety of defensive maneuvers that are fostered and reinforced by such anger. Finally, in the midst of a personal distress reaction the shamed individual may subsequently blame the distressed or injured party as a means of reducing their own pain. Thus shame-prone persons bring to their relationships a number of liabilities that may be particularly exacerbated during unpleasant interpersonal exchanges (Berkowitz, 1989; Tangney, 1991; Tangney et al, 1992).

Family Relationships

Systems theory and object relations theory correspond in the study of eating disorders. Theorists propose that the dynamics of the family system maintain the insufficient coping strategies seen in eating disordered individuals (Humphrey & Stern, 1988).

Humphrey and Stern (1988) contend that these ego deficits are the result of several failures in the mother-infant relationship of an eating disordered individual. One failure was in the mother’s ability to consistently comfort the child and care for her needs. Without this consistency, the infant is unable to develop a strong sense of self and will have no trust in the environment. Furthermore the child cannot discriminate between a biological need for food and an emotional or interpersonal need to feel secure (Friedlander & Siegel, 1990). The absence of this secure environment for the infant to gets her needs met inhibits the individuation process of being autonomous and expressing intimacy (Friedlander & Siegel, 1990). Johnson and Flach (1985) found that bulimics perceived their families as emphasizing most forms of achievement except recreational, intellectual or cultural. Johnson and Flach explain that in these families the bulimic has not sufficiently individuated to be able to assert or express herself in those areas. These autonomous activities also conflict with their role as the "bad child" or scapegoat.

The eating disordered individual is a scapegoat for the family (Johnson & Flach,1985). The parents project their bad selves and their sense of inadequacy on the bulimic and anorexic. The eating disordered individual has such a fear of abandonment that they will fulfill this function. Although the parents also project their good selves onto the "good child", the family may also see the eating disordered individual as the hero since they ultimately lead the family to treatment (Humphrey & Stern, 1988).

Families that maintain eating disorders are often very disorganized as well. Johnson and Flach (1985) found a direct relationship between the severity of symptomology and the severity of disorganization. This coincides with Scalf-McIver and Thompson’s (1989) finding that dissatisfaction with physical appearance is related to a lack of family cohesion. Humphrey, Apple and Kirschenbaum (1986) further explain this disorganization and lack of cohesion as the "frequent use of negativistic and complex, contradictory communications" (p. 195). Humphrey et al. (1986) found that bulimic-anorexic families were ignoring in their interactions and that the verbal content of their messages contradicted their nonverbals. Clinicians and theorists propose that these individuals’ dysfunction is in regards to food for certain reasons. The rejection of food or the purging is likened to the rejecting of the mother and is also an attempt to get the mother’s attention. The eating disordered individual may also choose to restrict her caloric intake because she wants to postpone adolescence due to her lack of individuation (Beattie, 1988; Humphrey, 1986; Humphrey & Stern, 1988). Binges are an attempt to fill the emptiness from a lack of internalized nurturance. The binging is also related to the eating disordered individual's inability to determine whether they are hungry or need to soothe their emotional tensions. This inability is a result of the inconsistent attention to their needs as a child. This care effects the quality of attachment between mother and child as well (Beattie, 1988; Humphrey, 1986; Humphrey & Stern, 1988).

The research has not significantly focused on attachment and separation theories to explain eating disorders because it did not view the theories as predictive or explanatory. However, Bowlby (as cited in Armstrong & Roth, 1989) proposes that eating disordered individuals are insecurely or anxiously attached. According to his attachment theory, an individual draws close to an attachment figure to feel secure and soothe their anxieties. Bowlby believes that the eating disordered individual diets because she thinks that will create more secure relationships which will help alleviate the tensions she cannot handle herself (Armstrong & Roth, 1989). This coincides with Humphrey and Stern’s (1988) belief that eating disorders function in varying ways to alleviate the emotional tension that they are unable to alleviate themselves. Other research has supported Bowlby’s theory as well.
Becker, Bell and Billington (1987) compared eating disordered and non-eating disordered individuals on several ego deficits and found that fear of losing an attachment figure was the only ego deficit that was significantly different between the two groups. This again supports the relational nature of eating disorders. Systems theory and object relations theory also explain why this disorder occurs predominately in females.

Beattie (1988) contends that eating disorders occur much more frequently in females because the mother often projects her bad self onto the daughter. The mother frequently sees her daughter as a narcissitic extension of herself. This makes it very difficult for the mother to allow her daughter to individuate. There are several other aspects of the mother-daughter relationship that impedes individuation.

The daughter’s relationship with her primary caretaker, the mother, is strained regardless of any family dysfunction. The daughter has to separate from her mother in order to develop her separate identity, but she also needs to remain close to her mother to achieve her sexual identity. Daughters also perceive themselves as having less control over their bodies because they do not have the external genitalia that lead to a sense of control over their bodies. Consequently daughters rely on their mothers more than their sons (Beattie, 1988). Researchers have used several different strategies to collect the data of eating disordered individuals. These studies have used self-report measures and observational methods (Friedlander & Siegel, 1990; Humphrey, 1989; Humphrey, 1986; Scalf-McIver & Thompson, 1989). Studies on eating disordered individuals have also used several different sampling procedures. Clinical populations have frequently been compared to non-clinical populations as controls. However, studies have classified female college students with three or more eating disordered symptoms as a clinical population. Researchers have studied the parents of bulimics and anorexics as well as the entire family (Friedlander & Siegel, 1990; Humphrey, 1989; Humphrey, 1986 & Scalf-McIver & Thompson, 1989). Separation-Individuation Process and Related Psychiatric Disturbances. There are several ways that an unhealthy resolution of the separation-individuation process is manifested. The child attempts to individuate from the mother figure when the child is around two years of age and again during adolescence. Without a successful resolution as a toddler, there will be extreme difficulties when the adolescent attempts to individuate. These difficulties often lead to psychiatric disturbances (Coonerty, 1986).

Individuals with eating disorders and borderline personality disorders are very similar in their unsuccessful attempts to individuate. This is why they often present as a dual diagnosis. Before explaining their specific similarities, it is necessary to explain the stages of the first separation-individuation process (Coonerty, 1986).

The infant becomes attached to the mother figure during the first year of life, and then the separation-individuation process begins when the infant realizes that they are a separate person from the mother figure. The child then begins to feel as though the mother figure and herself are all powerful and does not rely on the mother figure for security. The final stage is rapprochement (Coonerty, 1986; Wade, 1987).

During rapprochement, the child becomes aware of her separation and vulnerabilities and seeks security again from the mother figure. Separation and individuation does not occur when the mother figure cannot be emotionally available to the child after she separated. Theorists believe this originates with the mother figure’s only initial attempt at individuation which was met with emotional abandonment from her mother (Coonerty, 1986; Wade, 1987).
When the child becomes an adolescent her inability to individuate again can result in eating disorder symptomology and borderline personality disorder symptomology such as attempts at self-harm. The child felt self-hatred for wanting to separate from the mother figure; therefore, these self-destructive behaviors are ego syntonic. These acting out behaviors of adolescence are attempts to regain emotional security while exercising dysfunctional autonomy. Furthermore, both sets of symptoms result from the lack of self-soothing mechanisms that make individuation impossible (Armstrong & Roth, 1989; Coonerty, 1986; Meyer & Russell, 1998; Wade, 1987).

There is a strong connection between eating disordered individuals’ and borderlines’ failed separation and individuation, but other psychiatric disturbances are related to separation-individuation difficulties as well. Researchers have found adult children of alcoholics and codependents in general to have difficulties individuating from their family of origin (Transeau & Eliot, 1990; Meyer & Russell, 1998). Coonerty (1986) found schizophrenics to have separation-individuation problems, but specifically they do not have the necessary attachment with their mother figure and they differentiate too early.