With regard to eating disorders, attachment theory makes clear long-standing patterns that can be challenging to grasp otherwise. Often, individuals with eating disorders feel disconnected and set apart from family members, and yet yearn for meaningful relationships with these same family members. These individuals can feel confused about these opposing feelings, with little direction on how to resolve them. Attachment theory helps to illuminate why and how these relationships can become strained, and provides useful insight into how these relationships can be strengthened and utilized in eating disorder treatment. After a brief review of attachment theory, the use of the father-daughter relationship in eating disorder treatment will be discussed, with attention to specific interventions that may guide treatment in this area.

Attachment Theory
As children develop expectations of others, their future cognitive, behavioral, and emotional responses are guided. These responses are tied to one’s mental perception of self. Thus, if a child sees himself as capable, his responses with others will reflect that sense of capability. Children who perceive parents as warm and responsive often will perceive themselves as loved and valued, and they develop the expectation that their needs will be met. Conversely, children may come to view themselves as rejected and unloved when they view their parents this way, regardless of the good intent of most parents. These children learn to expect little from the world around them, and rather than looking to self and relationships for meeting needs, these individuals develop alternative strategies to cope with emotional stress.

It is important to note that these coping strategies are based on one’s perception–not necessarily reality. And, as many clinicians know, there can be vastly different perceptions for members of the same family. Certainly, the intent is not to blame parents for children’s unmet needs, but to help both parents and daughters be sensitive to, and willing to change, the ways they interact and deliver their good intent to one another.

Often, as individuals are faced with unmet attachment needs they turn to insecure coping strategies as an attempt to meet needs. Insecure coping strategies include attempts to both minimize or maximize one’s expression of attachment needs. Those who rely on minimizing strategies turn away from emotional distress, which results in limited emotional access and negative, unrealistic views of parents’ emotional availability. These individuals tend to believe that no one can ever meet their needs, and may even believe that they are undeserving of getting their needs met. In contrast, those who rely on maximizing strategies tend to turn their attention towards their emotional distress, often resulting in relationship enmeshment and difficulty assessing threats to others’ availability. Thus, these individuals tend to be riveted by fears about abandonment and may take extreme measures in an effort to meet attachment needs.

Individuals with eating disorders can often use both minimizing and maximizing strategies in their efforts to cope with unmet attachment needs, but are most often characterized as turning away from all needs, be those emotional, cognitive, or physical, as a way of disavowing the pain of unmet needs.

Thus, eating disorders represent one way of coping with attachment concerns. What emerges from investigations of attachment and eating disorders is a picture of a young woman turning away from emotional distress through externalizing strategies, including attempting to control her world through attempting to control her eating behavior and body. These individuals divert attention to their bodies, eating behavior, and other external pursuits because they are unable or unwilling to examine their own psychological states. This diversion allows individuals with eating disorders to avoid attachment concerns by focusing on the more external and more “attainable” goal of body change.

Using the Father-Daughter Relationship in Treatment
While not much is known regarding the father-daughter relationship and eating disorders, recent efforts have sought to illuminate this relationship. Research documents the need for clinicians’ attention to the father-daughter relationship as part of comprehensive care for eating disorders. In my experience as a clinician, I have seen that careful consideration of how fathers may be utilized in eating disorder treatment leads to more healing and long-term recovery.

While much attention is given the mother-daughter relationship in eating disorder treatment — and with good reason — often overlooked are efforts to understand and explore the father-daughter relationship. This can happen for several reasons, be it the many significant treatment concerns, limited time, or clinician hesitation. Regardless of the reason, examination and understanding of the father-daughter relationship can be critical to treatment and recovery from an eating disorder, and represents an important area of focus that can have a lasting impact in the lives of both the daughter and father. Through the use of five key exploratory questions and case example responses, the importance of utilizing the father-daughter relationship in eating disorder treatment is discussed.

How does client describe relationship with father?
Often clients report having distant relationships with their fathers, whether this is due to physical or emotional absence. Women’s descriptions of their fathers include: “he was always really busy,” “he travels a lot,” and “he was never really around.” Apparent in the responses of many individuals is emotional disconnection from their fathers. While this is a common response, the other response is one of being cared for or protected by one’s father. Sometimes, fathers may act as buffers between discordant relationships between mothers and daughters. Often the relationship, even among adults, is a one-up, one-down relationship in which the father takes the traditional role of protecting or “taking care” of the daughter.

Exploring this question with clients assists the clinician in understanding general family dynamics, and the specific relationship between the daughter and father. It also helps illuminate some of the client’s beliefs about the role of a father specifically, and men more generally. Identifying an emotional disconnection between and father and daughter can pave the way for establishing such a connection and helping the client to heal with the support of family. What messages were received regarding food, eating, and body image? This question addresses with more specificity issues that can potentially contribute to the development and maintenance of an eating disorder. Clients may respond with answers such as “my dad teased me that I was chubby,” “he often criticized my mom for being fat, and she wasn’t,” and “watch what you eat, or no one will want to date you.” One client indicated that her father agreed to pay her in order to lose weight. Often, individuals receive very critical messages linking desirability with weight and appearance, whether this be through direct routes such as payment for weight loss, or through more indirect routes of criticizing one’s mother or women in general.

Clients also report receiving mixed messages about weight, food and appearance. For instance, one client reported being chided by her father for taking snacks, but then her father demanded that she clean her plate when he prepared dinner for the family. These clients can often lose touch with their intuitive hunger and satiety cues when such mixed messages are presented in the family. Sometimes fathers can make love and connection contingent on food issues, such as the father playing “chef” and requiring the family to eat all that was presented to them as a way of affirming his own needs.

Understanding the messages about food, weight, and appearance helps the clinician take a step into the client’s world, and gain a greater appreciation for the very real fears that exist around food issues. Recognizing that for some clients, their belief about whether they are worthy of love, connection, and nurturing is intimately tied to issues of food, can help clients to be more sensitive to their experience, thus strengthening commitment to changing this connection. Inherent in these responses is also the idea of acceptance being contingent on a specific weight or appearance. Many women begin to question whether they are acceptable because they see that to their fathers their own mother may not be acceptable at a given weight. This leads to distrust of one’s own experience and a reliance on external indicators for validation and acceptance. Helping clients make this pattern clear is important treatment work–work that can help the client shift her focus from external sources of validation to more internal sources.

What are father’s expectations for daughter and attitudes toward women? Individuals with eating disorders often indicate that their fathers have high, unrelenting expectations of them, whether this be academic, athletic, or financial achievement. Fathers often transmit their own worries to their daughters through messages such as “you need to be pretty and marry someone with money.” It may be the case that these fathers push their daughters towards academic achievement and “catching a rich man” because doing so may relieve the father’s worries about providing for his children. Further, this traditional view conveys the message that the daughter’s appearance is the most important feature in determining her success. While during adolescence some of these fathers may push their daughters to achieve athletically, as daughters begin college the focus can often shift to achieving academically.

For many women with eating disorders there is an intense fear of disappointing others, and this no truer than in the father-daughter relationship. Often these women will go to extreme measures in order to receive the love, warmth, and care they desire from their fathers, even if this means pushing oneself to the limits in multiple areas. Helping clients understand this starvation for emotional attention from their fathers, as well as helping fathers understand this dynamic, can allow clients to more directly meet their needs and fathers to be more present in helping to meet those needs. Helping clients and fathers differentiate between acceptance and approval can help each let go of unrealistic expectations and instead build a relationship based on acceptance and love.

What are daughter’s expectations of father in family? Contrary to what some clients believe, expectations and assumptions within the family are not wholly unidirectional. Often, daughters have expectations about their fathers that keep them from developing strong emotional connections. Some of these expectations include “my dad makes sure we have food on the table,” “my dad can’t understand emotions,” “my dad’s too busy for me,” and “my dad’s not interested in my life.” These responses convey a belief of the father as only a provider, emotionally removed, and unable or unwilling to understand emotions. Often these clients may not even consider their father as an emotional resource to them in their eating disorder. Exploring the client’s expectations can help her take responsibility for her role in the emotional disconnection and can help her challenge her beliefs around role rigidity.

Often fathers are desirous to help their daughters in any way possible, but require an invitation to be allowed into the emotional lives of their daughters. Clinicians can do much to make these invitations easier to offer and receive by providing support to both clients and fathers in this process, and helping each see the good intent of the other. In some instances, it can be very therapeutic for clients to work with male clinicians, whether this be in individual therapy, group therapy, or other structured therapeutic settings so that clients can challenge their belief that men cannot understand or express emotions. Working with a male clinician who is not afraid to express and utilize emotions therapeutically can do much to create a corrective experience for these clients.

How does father respond to eating concerns? Fathers may respond to a daughter’s eating concerns in various ways, be that a reliance on practicality (“just eat”) or complete avoidance of the issue. Client responses to this question range from “my father has never said a word,” to “Have some broccoli. It’s good for you and it won’t make you fat.” It’s unclear which response is more troubling–no response at all, which serves to minimize the daughter’s experience and suffering, or a wholly practical response which fails to grasp the complexity of the eating disorder. Either way, these responses tend to undermine the daughter’s efforts to receive help. They may reinforce her belief that “nothing is wrong,” or the belief that her concerns are not valid and that she is not worthy of concern.

Father’s avoidance of the eating concerns can be in response to the troubling experience of seeing one’s daughter struggling but of not knowing how to help. This can be deeply painful for fathers, and rather than pushing through that pain and fear, they may turn to avoidance of the issue. Tragically, daughters may interpret their father’s silence as a sign of uncaring rather than as a sense of helplessness, and may reject any efforts the father makes. Further, these daughters can call into question whether they are deserving of recovery when they interpret their father’s silence as indifference.

Sometimes when these fathers feel helpless, they may turn in anger to clinicians with such statements as “it’s your job to make my daughter better.” Although difficult, clinicians must overcome defensiveness, and instead listen to the underlying message in this, which is often fear and helplessness. Acknowledge the fear and the helplessness, help the father and daughter speak the same language, and provide a bridge between the daughter and her father.

It may also be difficult for some fathers to understand the underlying emotional complexities of the eating concerns, and unfortunately there may be few efforts on the part of professionals to help fathers understand, given that clinicians themselves are not free of biases regarding men’s use of emotions. Clinicians must be willing to examine and challenge their own views that prevent them from utilizing fathers in treatment. Some healing is best facilitated within the father-daughter relationship, and clinicians must be willing to utilize every resource available to them.

Utilizing Family Dynamics in Treatment
In addition to addressing key exploratory questions, clinicians must attend to and utilize family dynamics in treatment. Is there competition or jealousy within the family system? Unfortunately, at times family members may try to sabotage the father-daughter relationship in order to meet one’s own needs. What is the daughter’s role in the family? What would be the costs to the family if the daughter were to be well? These dynamics are complex and must be considered with care.

An understanding of family dynamics can help the therapist clarify the roles he or she might take in providing corrective emotional experiences for clients. For instance, might the therapist provide the role of nurturing mother in which the client can learn and test boundaries, and receive nurturing and acceptance? Is the therapist vulnerable to becoming an enmeshed mother, and how might she disentangle herself? Is the therapist replicating the role of the distant father? How might he be more emotionally expressive, thus allowing the client to be the same? Can the therapist be a nurturing father in which emotions are valid, and there can be acceptance without unrealistic expectations? Clinicians must be thoughtful in considering roles they can take for therapeutic gain. Of course, appropriate boundaries are paramount in this work, and clinicians must be hyper-aware of their own emotional responses when engaging in this way. The clinician must examine how the father-daughter relationship might be a source of strength and support in the challenging work of recovery. Two interventions that can be powerful are to have both the father and daughter write letters of love to one another, or to spend time talking with one another on the telephone.

One client, upon receiving disappointing grades, called to inform her father of the situation. This daughter had, in the past, felt considerable pressure from her father to achieve academically, and so while it was difficult for her to tell her father of the disappointing grades, she also desired his support and encouragement. One of the continuing questions for this client in therapy was “how can I be independent and still stay connected to my father?” The client’s phone calls to her father were attempts to navigate the challenging task of interdependence between adult children and parents. During the phone conversation, the daughter was able to reach out for support and share her disappointment in her grades, and her father was able to change the way he related to his daughter by expressing support and encouragement, rather than reiterating the disappointment his daughter already felt. Then, unexpectedly, the daughter received a letter in the mail from her father a few days later, in which he expressed his love, support, and encouragement, and in essence gave her permission to not feel pressure from him anymore. He shared his hope that she would be happy and could feel love from him instead of pressure. This letter, in addition to the phone calls of support, did so much to heal this father-daughter relationship. Further, the letter became a transitional object which the daughter could turn back to during difficult times and remind herself of the love and support she had from her father.

In addition to phone calls and letter-writing, clinicians are encouraged to enlist the support of fathers by inviting them to therapy sessions, whether this be physical attendance of family sessions or phone sessions. During a family session the father who said he would pay his daughter to lose weight apologized to his daughter for these hurts. He acknowledged the pain he caused his daughter and he asked how he could support her. These efforts to join the father in treatment and recovery can provide healing balm to families. Throughout the client’s subsequent therapy, she relied on this experience with her father as evidence of his love and good intent towards her.

Another effort that can have lasting impact in improving family relationships is encouraging father-daughter time. While mothers and daughters can often find common ground for interactions, this can be more challenging for fathers and daughters. It may help to have a specific activity or focus of the time together, such as attendance at a sporting event, engaging in a hobby, or playing a board game. One daughter described a Friday night in which she and her father attended a professional hockey game. In describing this event, she reported “this was the first time my dad and I have really talked. We talked for three hours straight–just the two of us.” Such interactions allow fathers and daughters opportunities to really get to know one another. This can be particularly helpful for daughters who have rigid role expectations for their fathers. For instance, it can be enlightening for a daughter to learn that her father has interests and roles outside that of being a “provider.”

Cultivating the father-daughter relationship can buoy a daughter during treatment and recovery. So many of these individuals struggle with a sense of worth, and yet receiving messages from their fathers asserting their value and worth can have lasting impact. One daughter spoke of her father sitting her down and telling her that he loved her, that she had worth beyond measure, and that it did not matter what her achievements or failures were. Direct messages, such as this, are often required for these clients as their feelings of self-loathing can be intense and all-encompassing. This daughter, after one such conversation with her father, reported “my dad loves me, so maybe I’m okay.” This love and acceptance, communicated by a loving father, served as a bridge to this daughter in gaining a greater sense of her own worth. As she received love and acceptance from her father, she was able to strengthen her own belief in her worth. These messages of love are most powerful when coming from loved ones with a shared history.

There are caveats to addressing the father-daughter relationship in eating disorder treatment. First, it’s important to know how this client may be unique. Clinicians must strive to understand the complexities of these relationships. Utilization of the father-daughter relationship may not always be appropriate, such as if the father has a competing agenda, if the father is unwilling to address concerns, if there is intense rigidity in the family system, or if there is a history of incest or abuse perpetrated by the father. Clinicians must harness all their clinical skill and do well to seek consultation and supervision in determining whether enlisting the father in treatment would be therapeutic. And, if during the course of this work, it becomes apparent that the father may not be used as a source of support, the clinician must be willing to re-direct efforts, and must help the client recognize that the father may not be a source of support. Although many clients have not utilized fathers for support, it can still be incredibly difficult to come to terms with the fact that the father cannot be enlisted. This is a loss that must be grieved by the client. While doing this work, the clinician must be sensitive to the developmental needs of the client. In exploring developmental needs, clinicians do well to ask the question, “where is this client stuck?” At what developmental age is this client? What are her needs at this point, and how might a nurturing father help to meet these needs? For instance, is the daughter a developmental 13 year-old wherein she needs firm structure with room to develop her own individuality? Or, is she a developmental 11 year-old who feels overwhelmed with the thought of growing up and needs the safety of love from her father? Exploring these developmental questions can guide clinicians to the most valuable areas of treatment foci.

In addition to sensitivity regarding a client’s developmental level is a clear understanding of the client’s readiness for change. Clinicians must be cautious about moving into this work too quickly without having a clear sense of the family system. Moving too quickly may overwhelm the client, the family, and the clinician. Many clients are not prepared, initially, to utilize their fathers in treatment, and this must be broached with patience and care. Pacing is paramount in this work, as is providing a clear path of the work so that fathers and daughters alike may know what to expect. Exploring client hesitations will help the clinician accurately assess the safety of this work as well as helping the clinician know when it is safe to push forward and when it is important to slow down.

Conclusion
Attachment theory is well suited for conceptualizing the complex family relationships often present in eating disorder treatment. The father-daughter relationship represents one potentially important influence, and careful assessment and appropriate use of this relationship can be key to successful treatment and long-term recovery.

Some Clinical Considerations

1. Clarifying whether use of the father-daughter relationship is appropriate
   
2. Sensitivity to the developmental needs of the client
   
3. Sensitivity to the client’s readiness for change
   
4. Pacing as critical to establishing safety for both clients and fathers
   
5. Providing a clear path of the course of father-daughter work
   
6. Father-Daughter Interventions
   
7. Encourage daughter’s direct invitation of father as source of support
   
8. Telephone calls and letters of love and encouragement between father-daughter
   
9. Father participation in therapy, either by phone or in person
   
10. Encourage father-daughter recreational activities
    
11. Encourage father’s direct messages of love and support

1. Join anti-fattist groups, such as NAAFA, the National Association to Advance Fat Acceptance.
   
2. Appreciate the artwork of such artists as Renoir, Gauguin, Titan, and Peter Paul Rubens. Each artist appreciates the bodies of curvy women.
   
3. Research history. There have been times when fat has been in-style and promoted by the medical community.
   
4. Travel to or find information about countries that promote fatness, such as the countries in Africa.
   
5. Read the Health at Every Size journal.
   
6. Appreciate the beauty and diversity of all body shapes and sizes.
   
7. Criticize the media’s perception and image of beauty.
   
8. Question the validity, safety, and effectiveness of weight loss tools and products.
   
9. Focus on fitness instead of fatness.
   
10. Practice body acceptance.

1. Extensive evaluation and assessment process
   
2. Medical stabilization and monitoring
   
3. Ongoing laboratory checks and medication evaluation
   
4. Specialized structure for managing eating disorder symptoms and patterns
   
5. Body image and body movement groups
   
6. Weekly dietary sessions, real-life dining experiences, and nutritional counseling
   
7. Intuitive eating model
   
8. Dialectical Behavior Therapy (DBT)
   
9. Specialty groups focusing on trauma, abuse, anxiety and depression (optional, depending on patient need)
   
10. 12-Step group for addictive patterns
    
11. Life skills training including cooking classes
    
12. Art and experiential groups