Subtle Breaks In Attachment: Invisible Trauma And The Emergence Of Bulimia Nervosa
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Subtle Breaks In Attachment: Invisible Trauma And The Emergence Of Bulimia Nervosa Antonia Saunokonoko ( antonia.saunokonoko@laureate.edu.au ) Torrens University Australia https://orcid.org/0000-0002-7127-7520 Michelle Mars Torrens University Australia Werner Sattmann-Frese Torrens University Australia Research Article Keywords: Bulimia nervosa, father-daughter relationship, complex trauma, eating disorder, hermeneutic methodology Posted Date: April 15th, 2021 DOI: https://doi.org/10.21203/rs.3.rs-421558/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License
SUBTLE BREAKS IN ATTACHMENT: INVISIBLE TRAUMA AND THE EMERGENCE OF BULIMIA
NERVOSA
Dr Antonia Saunokonoko, Torrens University Australia (Corresponding author)
Dr Michelle Mars, Torrens University Australia
Dr Werner Sattmann-Frese, Torrens University Australia
1SUBTLE BREAKS IN ATTACHMENT: INVISIBLE TRAUMA AND THE EMERGENCE OF BULIMIA
NERVOSA
Abstract
Background: It is known that complex traumatic experience contributes to the emergence
of bulimia nervosa (BN). Yet cognitive behavioural therapy, with or without medication,
remains the western medical model’s treatment of choice, regardless of its poor long-term
outcomes. Incidence of BN is rising, whilst treatment success eludes most sufferers. This
research set out to dig deep into the lived experience of BN in order to uncover new clues
linking BN’s aetiology to treatment options; and the research argues for the adoption of
trauma-informed protocols for BN, as these fit more effectively with causation. Taking the
previously under-researched, but known-to-be significant father-daughter relationship as its
starting point, the research reveals a raft of new findings pointing to the pervasive
consequences of subtle attachment trauma in this relationship. In light of this, the research
informs a clear recommendation for a trauma-informed treatment approach and provides
hope for those living with the condition. Methods: A hermeneutic phenomenological,
detail-rich study of women in recovery from BN was carried out. A qualitative study was
considered to be in sufficient contrast to existing research approaches as to offer up the
greatest possibility of new insights into BN. Results: Subtle attachment failures, present in
the father-daughter relationship, strongly contribute to complex traumatic experience and
are instrumental in the development of BN. Many of these attachment failures lack the
overtly dramatic nature of abuses such as physical violence, yet create powerful pre-
conditions for the development of bulimic symptomatology. They are rooted in safety-
seeking and survival aspects of the attachment bond, causing confusion in aspects of self-
2worth and anxiety about belonging. The resulting uncertain search for secure nurturing is
directly reflected in the push-pull dynamic of the binge/compensation cycle of BN.
Conclusions: BN arises in response to complex traumatic experience as a survival
mechanism aimed at ensuring psychological and physical protection. Complex traumatic
experience is, however, a multi-faceted concept in which subtle breaks in father-daughter
attachment play a pivotal role. Therefore, adopting a staged, multi-modal complex trauma
treatment model, aimed at building safety, agency and relationship skills for those seeking
help, may offer hope for more successful treatment outcomes.
Key words: Bulimia nervosa, father-daughter relationship, complex trauma, eating disorder,
hermeneutic methodology.
31 Plain English Summary
2 This research explores the complexities of trauma in the father-daughter
3 relationship in families where bulimia nervosa emerges in a daughter. It sheds light on why
4 bulimia does not respond to the treatment currently offered by the medical community and
5 recommends an alternative treatment approach with greater likelihood of success. The
6 research reveals that the father-daughter relationship is a source of ongoing subtle
7 attachment failures and that bulimia nervosa acts as a form of protection in the face of
8 emotional overwhelm and perceived threats to the Self. The findings highlight the fear and
9 insecurity at the root of bulimic symptoms and support a shift in treatment approach
10 towards the individualised, flexible complex trauma treatment model. This is capable of
11 closely addressing the causes of bulimia and aims to alleviate the need for the eating
12 disorder by helping the sufferer develop the sense of safety, resourcefulness and
13 connection they need.
14
15 Background
16 Since bulimia nervosa (BN) was first named by Russell in 1979 [1], it has been the
17 subject of extensive research by academics, the medical community and practitioners.
18 Defined in the Diagnostic and Statistical Manual of Mental Disorders (5th edition) [2] as one
19 of the major eating disorders, the seemingly counterproductive thoughts and behaviours
20 experienced by those living with BN can appear baffling to those with a healthier
21 relationship to food and eating.
22 Driven by an increasingly desperate obsession to lose weight or avoid weight gain,
23 the person with BN adopts a cycle of bingeing on very large quantities of food, followed by
24 compensatory action such as vomiting, compulsive exercising, ingesting laxatives and
425 diuretics, or fasting. Once this cycle, so characteristic of BN, takes root, it becomes resistant
26 to treatment in most cases, regardless of worsening physical consequences and punishing
27 psychological pain [3].
28 Bulimia nervosa is a condition that develops as a means of emotion regulation [4].
29 Bulimia is characterised by a push-pull dynamic that absorbs and distracts the sufferer from
30 underlying emotional challenges [5]. Outwardly, there is a focus on controlling food, body
31 size, shape and weight. Inwardly there is a profound fear of vulnerability and pervasive low
32 self-esteem, reflecting existing research findings that BN arises in families where nurturing
33 by caregivers is poor and parenting style involves heightened levels of conflict and control
34 [6,7].
35 The binge/compensation cycle also sets up biological difficulties for the sufferer.
36 Consumption of foods that are high in processed sugar, as occurs typically in a binge, release
37 dopamine and serotonin in the brain. These are associated with pleasure seeking and
38 positive mood states. However, the frequency with which binges occur increases the
39 number of dopamine receptors in the brain and makes it progressively more difficult for a
40 person to derive pleasure from alternative sources. In addition, processed sugar is
41 metabolised quickly by the body, meaning such binges are followed by a drop in mood and
42 fatigue, leading to cravings for more sugar. Therefore, BN not only affects a person socially,
43 emotionally and psychologically, but there are also resultant differences in brain chemistry
44 as well [8]. It can be a truly debilitating condition.
45 CBT, the treatment protocol usually advocated for BN, has emerged as the choice of
46 the western medical community as a result of it being the treatment practice explored most
47 commonly in evidence-based research. The theoretical justification behind this choice is
48 that if mood is stabilised and maladaptive thinking adjusted, behaviour will change and
549 recovery is possible. However, in reality, enduring recovery for BN sufferers treated by this
50 method is as low as 15.5% [3] and CBT has been criticised for some time by numerous
51 sources for its inability to help effect meaningful positive long-term change [9,10,11,12,13].
52 In order to progress the search to find more effective help for those seeking
53 recovery from BN, it was considered necessary to dig deeper into its aetiology and reveal
54 more of the meaning-making behind the symptoms of BN. This was a considerable challenge
55 because BN is a heavily researched condition and its aetiology has been broadly mapped
56 out. However, since existing research has not yet translated into successful treatment
57 protocols, it was hypothesised that there must still exist clues to better treatment that had
58 yet to be uncovered.
59 Previous research has highlighted the presence of abuse and lack of affectionate
60 nurturing in families where BN occurs [7]. It has also brought to light the potential
61 significance of the father-daughter relationship in the development of BN and there have
62 been calls for a study that would make this relationship its focus [14,15,16,17,18,19,20].
63 This study fills that gap; enabling a leap from understanding BN at a deeper level than
64 before, to recommending a treatment approach with a greater likelihood of success.
65 To date, the vast majority of studies about BN have adopted quantitative research
66 designs. Since BN is a condition detailed in the DSM-5 [2], BN attracts studies conducted
67 using methodologies that fit with the conventional medical model’s preference for
68 quantitatively evidenced research. This new study takes a deliberately contrasting
69 approach. It was considered essential to explore in-depth the experience of BN using a
70 qualitative methodology if new understandings of the condition were to emerge. This
71 turned out to be an important and advantageous decision, which has enabled a raft of new
72 findings to emerge.
673 Method
74 The methodology followed for this study was hermeneutic phenomenology, as
75 derived from the writings of Heidegger [21], Gadamer [22] and Van Manen [23] This is an
76 interpretive, qualitative methodology, particularly suited to in-depth, detail-rich research. It
77 is grounded in an assumption that the person and their world are co-constituting, and that
78 there are multiple and contingent realities of a phenomenon waiting to be uncovered [21,
79 24]. It takes as a starting point that researchers can only ever be subjective and operate
80 from within their context; and, therefore, that the pre-suppositions emerging from this
81 context must be made transparent.
82 Since hermeneutic phenomenology aims to capture the meaning-making and the
83 subjectivity inherent in being alive in the world, it was hoped it would provide deeper access
84 to the experience of BN, without excluding the context of that experience. The methodology
85 also minimises the use of research rules and structures. It does not seek to create an
86 objective hierarchy of findings or generate theory. Instead, it allows for the most evocative
87 interpretation of experience to surface. This was decided to be the most likely route to
88 uncovering new clues for treatment direction.
89 The method used was guided by the six steps detailed by Van Manen [23], which
90 encourage a multi-faceted involvement with the focus of the research; deep reflection on its
91 essential themes, both in constituent parts and as a whole; writing and re-writing in order to
92 develop an understanding of the phenomenon; and use of the hermeneutic circle, in which
93 participants are given the opportunity to provide feedback regarding the validity of the
94 researcher’s interpretations.
95 For this study, a sample of six participants was recruited. A small sample size is
96 common with this method [25, 26, 27]. Since most reported cases of BN are amongst
797 women, all the participants were female. All had lived with BN, were over the age of 21 and
98 had a minimum of 18 months’ continual recovery from the condition. All the participants
99 had grown up in households where both the biological mother and father had been present
100 throughout childhood. None of the participants was active in any other eating disorders or
101 addictions. Recruitment took place using the snowball method and all participants had to be
102 active members of 12-Step food fellowships, such as Overeaters Anonymous, in order to
103 ensure all had established networks of support.
104 Each participant was interviewed for one hour either in their own home or in a
105 neutral location, according to their choice. Interviews were unstructured and the dialogues
106 were captured via audio recording and then transcribed into texts. These texts are
107 acknowledged in this methodology, not as factual accounts, but as initial transformations of
108 experience into language, which may then be reflected upon and interpreted. All
109 participants are referred to in the research by pseudonyms they selected for themselves.
110 Field notes were written by the researcher after each interview, documenting
111 elements that could not be captured by audio recording, such as body language and home
112 surroundings. The researcher also maintained a reflexive diary throughout the research
113 process, noting pre-judgements, observations, hunches, thoughts, reflections and points of
114 identification with the participants. A further source of information brought to the
115 interpretive process was research conducted post-interview around cultural references
116 raised by the participants during their interviews, such as music, books and religious
117 matters.
118 The texts of the interviews were read and re-read following Van Manen’s [23] three-
119 fold approach: wholistic, selective and detailed, moving between readings to uncover
8120 insights and themes. Interpretations were contextualised using all the information gathered
121 during the research process.
122 Validity and reliability are not terms closely associated with this methodology, but
123 the issues of research rigour, scholarly integrity and credibility of findings remain essential
124 and pertinent. Whilst generalisability in the quantitative sense is not possible, Moules et al.
125 [28] suggest that transferability is a term with a better fit for hermeneutic research and
126 there is also analytic potential in recognising recurring aspects of the meaning of a
127 phenomenon. In addition, there is a vital requirement for research of this kind to be
128 reflexive and transparent, as well as for evidence to be credible and interpretations
129 recognisable to others. Thus, for this study, the methodology and method were
130 painstakingly laid out and justified; findings discussed with co-researchers; and
131 interpretations shared with co-researchers and participants prior to final writing.
132
133 Results
134 The use of a hermeneutic phenomenological methodology enabled a raft of new
135 findings to emerge, rich in the meaning-making accorded to the experiences of those who
136 have lived with BN. Included here are seven key findings, specific to the father-daughter
137 attachment relationship. They illustrate clearly how the daughter attempts to resolve veiled
138 traumatic breaks in attachment through the adoption of BN; and that BN provides a logical,
139 functional and protective strategy for survival in the face of the indistinct, felt sense of
140 threat to the Self that these subtle traumas evoke.
141
142
143
9144 1. Dysfunction at mealtimes
145 The link between attachment difficulties and adoption of bulimic symptomatology
146 has not be fully explained in extant literature. After all, not all children experiencing
147 attachment difficulties go on to suffer from BN. This research, however, shed light on why
148 BN arises in certain households and not in others. The research revealed that the
149 attachment difficulties experienced between father and daughter in homes where BN
150 emerges in the daughter, are played out over mealtimes where food is present.
151 Louise’s father was a larger-than-life character. He was very domineering and an
152 alcoholic who could be distant, bullying and abusive. Louise recalled an incident at the
153 dinner table when her father forced her to eat a food she hated. She recalled crying into her
154 meal and the food splashing into her face as he shouted at her. For Louise, food became a
155 battleground of which she was determined to take control.
156 This study revealed the ‘quiet’ traumas that deeply affected those who developed
157 BN. Nina couldn’t recall family mealtimes after her brother, who was seven years older than
158 her, left home, despite eating daily with her parents around the table. However, Nina could
159 recall food that lacked flavour or enjoyment. Her father adhered to orthorexic practices
160 around food and was the main cook in the house. There was no sugar, salt or processed
161 foods allowed. Meals were “boring and bland” and as a child Nina felt her needs and wishes
162 around food were ignored and shamed. Her mealtimes were never a source of pleasure or
163 comfort and this fed a desire to derive as much pleasure from food in private as she could.
164 Anne’s family sat around the table together for dinner most evenings. Her father was
165 depressed and unpredictable and was frequently uncommunicative. Anne grew up not
166 understanding why other families talked to one another around a dinner table. Her family
167 ate in silence or watched television from the table. No one asked about her day or inquired
10168 as to how she was doing. There was little connection between family members. Anne
169 mostly only connected with the food on her plate.
170
171 2. Belonging
172 An essential outcome of secure attachment is a felt-sense in the child that it belongs
173 with its caretaker and will be reliably provided with safety as a result [29]. In families where
174 bulimia arises, secure attachment is absent in up to 100% of cases [30]. This research
175 revealed that in relation to attachment, where BN arises, father is an equally important
176 figure as mother, regardless of whether he is the primary caregiver or continually present in
177 the home; but he is not experienced as a consistent source of safety. The conditionality of
178 the father-daughter attachment bond creates an unmet longing in the daughter within this
179 dyad, for father’s approval and protection. Security is sought but regularly frustrated, and
180 the failure to effect in father the secure attachment that is so desperately needed, results in
181 the daughter developing poor self-worth and a tendency to self-punish.
182 For example, Kate grew up with her father in the house. However, he was a distant and
183 uninvolved parent who worked away a lot. His absence exerted a major influence on Kate’s
184 ability to form relationships with men that remains with her decades later: “There’s not a
185 man in my life, there’s not a man in my house, there’s not a man in my energy zone,
186 because that’s what I’m used to.” Kate described isolation and bulimia as her ‘go-tos’ when
187 she felt emotionally neglected by her father. She found solace and soothing in the
188 sweetness of binge foods. However, her view of herself as unworthy of love, as a result of
189 the casual rejections she experienced with her father, left her feeling unworthy of the
190 comfort the food provided, so she would vomit and externalise the self-disgust she needed
191 to express.
11192 Belonging is vital to human survival. The low-key rejections of a daughter by her father
193 over the span of a childhood trigger the survival response of fight-flight-freeze. These
194 rejections can be as unremarkable as an annoyed tut and a sigh if the child asks for help,
195 signalling the father is too busy and does not wish to be bothered. These rejections may
196 appear minor or harmless. But in combination with an array of neglectful, hurtful or
197 explosive acts of abuse, Kate was left with a sense of unease and a fear of having only a
198 tenuous hold on her father’s attention. The small details of attachment breaks appear to be
199 instrumental in repeatedly activating the need for comfort and the desire for self-
200 flagellation for wanting that comfort. This is reflected in the binge/compensation of BN.
201
202 3. Visibility
203 An attachment behaviour engaged in by children is the pursuit of a caregiver’s
204 attention. Being seen and heard by the caregiver informs a view of the Self as loveable and
205 worthy, as well as being of value to the caregiver, which implies safety [31]. This finding
206 indicates that where bulimia emerges in a daughter, it has been signalled to her that her
207 needs are not noticed or valued. The research revealed that for all participants, their fathers
208 did not respond appropriately to the symptoms of their eating disorder, leaving them
209 feeling invisible and unimportant.
210 When Louise’s father discovered from his wife that Louise was struggling with
211 bulimia and that she was so weak she had trouble even walking up stairs, his only response
212 was to say to Louise “I’m sorry that things are so bad for you”. “And that was it, really”
213 Louise stated in summation. His lack of proffered help was echoed in Anne’s recollection of
214 how her father responded to her vomiting after meals at home by belittling her when she
215 was eating and telling her she would get fat. Rebecca’s father’s reaction to her asking for
12216 help with her bulimia was for him to listen without comment until announcing he had to
217 leave. “I then felt bad for taking up so much of his time” she said sadly.
218 These daughters experienced a sense of unimportance as their difficulties were not
219 met with support or kindness. They internalised this as a belief that they were unworthy of
220 help. In response it seems that food became an increasingly necessary crutch for soothing
221 frayed emotions, both craved and feared. Just as the dynamic of bulimia is one that
222 expresses both desire and hatred – of the food, of oneself and of the sought-for-other.
223
224 4. Protection
225 Protection is a gender-normative role that has been attributed to fathers in extant
226 research [32, 33]. However, in the families of all the participants in this research, it seems
227 that the daughter who develops BN who steps into the role of self-protection because it is
228 left void by their fathers. Moreover, since their fathers were not a source of protection,
229 these daughters stepped into the role of protecting not just themselves, but often other
230 family members as well.
231 Kate’s mother was an alcoholic who became increasingly volatile and violent as
232 Kate’s teenage years progressed. Her father would abandon Kate and her siblings to the fear
233 and chaos that ensued. Kate told me: “when she was drunk and he was hiding it was all just
234 very unsafe…he wasn’t a safe haven”. Kate was placed in a position where she had to take
235 increasing responsibility for her younger siblings. The situation degenerated to the point
236 where her mother was throwing knives in anger. Kate begged her father to intervene, but
237 he announced it wasn’t safe for him anymore and left the family home, so Kate stepped in
238 to protect her sisters and found them somewhere else to live, away from their mother.
13239 There has been considerably less research conducted into the roles and effects of
240 paternal parenting than maternal parenting, but that has started to change [17, 34]. This
241 research demonstrates that an examination of the father-daughter relationship possesses
242 the potential to elucidate BN in new ways and lead to change in treatment approaches. The
243 research clearly indicates that the assurance of paternal protection is a vital source of
244 attachment security and in its absence there arises a fear of facing the unknown
245 consequences of danger and uncertainty alone. In the repeated presence of fear, the
246 hypothalamus-pituitary-adrenal axis is heightened for prolonged periods of time. The gut,
247 acting as a secondary nervous system, signals the presence of stress. This can trigger an
248 increased ingestion of high fat and high sugar foods, which in turn stimulates the increased
249 production of cortisol [35]. Therefore, stress can lead to bingeing, which plays a role in
250 stress relief. However, in families where BN develops, self-worth is often linked to body size
251 and shape, therefore the idea of weight gain becomes intolerable and the cycle of
252 compensation kicks in.
253
254 5. Absence of guidance and wisdom
255 An important finding from this study is that in families where BN arises in a
256 daughter, father does not provide advice, guidance or wisdom. This may not seem overtly to
257 be a source of trauma, but it compromises attachment and leaves the daughter feeling as
258 though she lacks the resourcefulness necessary to survive independently. Feeling
259 unprepared to navigate life’s ups and downs, the daughter experiences anxiety and
260 emotional overwhelm in response to many ordinary everyday situations.
14261 Rebecca explained this clearly: “I just wanted to know how to live life and I was
262 asking. I remember saying, ‘Dad, you’re so good at all of these things. Can’t you help me?’
263 And he would say, ‘I’m not a good teacher.’ That feeling of rejection.”
264 Claire had a cousin who had become a successful model in New York. Although still a
265 teenager, her family thought she was capable of following in her cousin’s footsteps.
266 However, Claire’s experience of modelling was one of harsh critique, rejection and having to
267 follow a punishingly restrictive diet. Claire was left with feelings of profound inadequacy and
268 burdened by thoughts of failure. Her father, who had taken the initial modelling shots of her
269 and encouraged this pursuit, offered up no words of comfort or guidance as her journey
270 unfolded. She was left unprepared for the adult world of work; there was no advice
271 regarding the processing of rejection and no encouragement to follow a different path.
272 Claire simply kept trying to please the agency and her parents, whilst soothing herself with
273 food and punishing herself with purging. It appears her emotional growth was limited by the
274 lack of guidance, because the adoption of BN deadened her feelings. This left her without an
275 internal compass that would have allowed her to identify the sources of her anxiety and
276 seek real-world solutions to them from alternate sources.
277 There was also a notable lack of spiritual guidance reported by all the participants in
278 the study. Spiritual beliefs provide a sense of belonging, safety and purpose in the world and
279 spirituality has a strong, evidenced relationship to well-being and healing [36, 37]. None of
280 those interviewed had received any spiritual guidance from their fathers, but had found it in
281 recovery through their participation in 12-Step fellowships and identified it as crucial to
282 reducing and relieving their fears in everyday situations.
283
284
15285 6. Marginalisation of attachment needs & sacrifice of Self
286 This research revealed that fathers whose views reflect a hierarchical value set
287 related to gender may impact the development of BN in their daughters. Traditional
288 attitudes towards gender, that favour boys over girls and attribute greater freedoms to the
289 former, may contribute to lower levels of paternal involvement with daughters and be
290 associated with attachment disruptions. Demidenko et al. [38] link less involved paternal
291 parenting in the early years of childhood to greater levels of adolescent depression,
292 something frequently co-existing alongside eating disorders.
293 Rebecca recalled “learning…there’s rules for boys and there’s rules for girls”. One of
294 her greatest objections was being made to help her mother prepare dinner in the kitchen
295 whilst her brother got to sit at the table chatting with her father as they waited for the meal
296 to appear. Rebecca felt deprived of her father’s time and attention. She also remembered
297 there being lower expectations for girls in her father’s eyes and the message being
298 conveyed to Rebecca that regardless of her achievements, she would never be enough, as a
299 girl, to fully gain her father’s approval.
300 This sense of not being good enough for father manifested in other ways in the lives
301 of the participants. In particular, the daughters who developed BN sought to subsume who
302 they really felt themselves to be in order to try to fit their fathers’ ideals. Claire’s older
303 brother had been born with severe disabilities and Claire described her experience of her
304 father thus: “…when I was born, even though he told me I was a mistake each birthday, it
305 was as though I was the boy he had wanted. He taught me how to fix the car…change tyres.
306 I was very much a tomboy. But when I started to go into puberty, I felt really disappointed
307 with myself that I was becoming a girl. I think this is all tied up with the eating disorder”. She
16308 observed something crucial to her attachment with her father: “…it seemed as though he
309 was more fond of me when I was doing the things he liked to do…”
310 This sentiment was echoed by others in the study. For example, Anne took up
311 gardening in order to spend time with her father, a keen gardener, but noted that she was
312 aware in retrospect that her participation was not about her own enjoyment of gardening,
313 but of wanting to please her father and gain access to time with him.
314 Sacrificing parts of themselves in order to appeal to their fathers, these women lost
315 touch with their more authentic selves. This is a common symptom in those suffering from
316 eating disorders [39] and most likely linked to a sense of shame instilled in them by their
317 father’s lack of interest in joining with them on a more equal footing. Shame is a known
318 contributor to the development of bulimia [40] and rejection plays a role in raising a child’s
319 anxiety levels [41]. These phenomena may have compelled these daughters to adapt,
320 chameleon-like, in order to connect with their fathers and relieve their attachment anxiety.
321 The push/pull dynamic, so indicative of BN, can be seen reflected in the desire for the safety
322 of connection, mixed with the fear of annihilation of the Self in seeking it. The body is
323 implicated in this struggle, whilst the psychological Self remains hidden, leaving behind a
324 sense of emptiness that only more food seems capable of filling.
325
326 7. Physical unavailability as a message of rejection
327 Emotional unavailability of fathers is a known contributor to the development of
328 bulimia in a child [20]. This research found that in addition to being emotionally unavailable,
329 fathers of women who develop bulimia exert physical unavailability as well and that this
330 communicates and reinforces a message of rejection to their daughters. Physical
331 unavailability is the kind of quiet trauma that this research has found to be instrumental in
17332 contributing to breaks in father-daughter attachment and resulting in a deep felt-sense of
333 fear and insecurity in those who develop BN.
334 All the participants grew up with both parents present in the family home. Yet for all
335 of them, their fathers chose to spend large amounts of time either working away, behind
336 closed doors when at home, or both. Anne described her father’s physical unavailability as
337 “withdrawing”. He had several sheds in their garden, even placing his piano in one of them,
338 and once installed out there, the family understanding was that he was not to be disturbed.
339 Anne recalled him being in the sheds for hours at a time and for long periods when the
340 weather was mild.
341 Louise’s father spent up to half the year away from the family home for work. On his
342 return from a trip Louise would seek to spend time with him. However, he would choose
343 instead to listen to music alone with the door shut, keeping other family members at bay.
344 “[The music] was loud [so] that everyone could hear it, but [he would] listen to it by
345 himself…I guess he was quite separate from us”.
346 The participants in this research felt this distance very deeply. They longed to access
347 their fathers and be validated by them. The physical distance enforced by their fathers
348 shored up the emotional distance that existed and left the daughters feeling unsure of their
349 worth to their fathers and in turn unsure of their own self-worth. This longing underlay
350 many of the behaviours aimed at perfecting their physical selves, in an attempt to make
351 themselves more appealing to their fathers. However, since the strategy of manipulating
352 their bodies through controlling food and exercise made no difference to the relationship
353 with their fathers, the punishing elements of the bulimic cycle seemed to be a way of
354 forcing themselves to try harder and avoid further failure.
355
18356 Discussion
357 The aim of this research was to understand why BN responds so poorly to the
358 treatment currently recommended by the medical community (CBT and medication); and
359 uncover a fresh direction for treatment that offers greater hope of success for sufferers. The
360 use of a hermeneutic phenomenological methodology allowed for a fuller unpacking of the
361 underlying contributors to BN than ever before and many new findings emerged that can
362 inform a way forward.
363 The research highlighted that in the aetiology of BN there lie many subtle
364 attachment breaks in the father-daughter relationship that feed into an experience of
365 complex trauma for the sufferer. Complex traumatic experience directly affects the limbic
366 system in the brain that responds to fear [42]. Bulimia nervosa provides respite, a
367 psychological prop and a refuge from a heightened adrenal system. The conventional way of
368 viewing bulimia: as a step away from normality involving an irrational set of thoughts and
369 behaviours, misconstrues the pragmatic importance of bulimia to survival in those in whom
370 it takes root. Since the limbic system is not controlled by conscious thinking processes,
371 recovery usually remains out of reach when treatment seeks to address thought processes
372 in the hope that behaviour changes will follow. It misunderstands how and why BN emerges
373 and the role it plays in survival.
374 Subtle attachment traumas play a very important role in undermining a felt sense of
375 safety and security in the father-daughter relationship. Up to 100% of BN sufferers
376 experience insecure attachment patterns [30], but complex trauma is a complex concept.
377 Overt abuses, such as violence, serious sexual abuse, harsh words and name-calling are
378 easier to identify as dangerous and threatening. Conversely, trauma without drama, such as
379 a closed door, a lack of showing interest or an absence of teaching about love, create subtle
19380 breaks in attachment that are ‘quieter’ and less easily identified and labelled. These,
381 however, can cause free floating anxiety and a pervasive sense of threat that cannot so
382 easily be attributed to something concrete. They contribute strongly to a heightened
383 adrenal response and a sense of longing. They communicate a lack of worthiness, a question
384 over belonging and an inadequacy of Self. There emerges a powerful desire to pull father
385 closer, but to simultaneously push out the emotional overwhelm of being in a relationship
386 with him.
387 Food and mealtimes are part of this threat, and nurturing is noticeably absent at
388 these times. Survival in a world without guidance, self-knowledge, validation or certainty
389 results in a fear of annihilation. An inner void emerges: an empty space to be filled. The
390 daughter in the eye of this storm must shore up her resources, protect her vulnerabilities
391 and hide. BN steps in to serve this purpose. But BN is not rooted in conscious cognitive
392 processes. In fact, it side-steps reasoning, it just feels ‘right’.
393 If treatment for BN sufferers is to be effective, it must encompass both meaning-
394 making and a felt sense of safety. Researchers have been calling for the adoption of the
395 complex trauma treatment approach for some time now [43, 44, 45, 46] and this research
396 confirms its potential relevance and applicability. The staged, multi-modal approach of the
397 complex trauma treatment model focuses on establishing safety and relationship skills
398 through treatment, and instils the BN sufferer with a sense of their own agency and
399 resourcefulness. The complex trauma treatment model addresses mind, body and spirit in a
400 flexible, individualised way, involving a range of approaches such as talking therapies,
401 somatic therapies and experiences aimed at interpersonal connection. These gently support
402 the sufferer to establish a sense of safety and re-connect with themselves, with others and
20403 with their wider world. Ultimately, it is these skills that will enable the sufferer to let go of
404 BN, because BN becomes a redundant strategy.
405 A limitation noted for this study is that all daughters were heterosexual. It would be
406 of interest to explore the father-daughter relationship as it relates to the emergence of BN
407 amongst women who identify with different sexual orientations. Further, the methodology
408 for this research utilises a small sample. It would be of great value to research the findings
409 amongst a larger sample in order to be able to generalise them.
410
411 Conclusions
412 This research reveals the necessity of viewing bulimia not as a mental disorder, but
413 as a condition arising from complex trauma. The relevance and advantages of doing so are
414 that this makes sense of why bulimia has been found to be resistant to CBT and medication
415 and also offers a different route for treatment moving forward. The findings detailed here
416 uncover the intricacies of the attachment trauma at play in the father-daughter relationship.
417 They also offer an explanation as to why food and the binge/compensation mechanism of
418 BN are adopted, in an attempt to address the difficulties that arise for the daughter in terms
419 of her lack of self-worth, feelings of rejection, felt-sense of danger and profound sadness
420 and emotional overwhelm.
421 BN is a manifestation of the interpersonal trauma being played out in the family and
422 in the father-daughter dyad in particular. Small, quotidian rejections and omissions in
423 paternal parenting, so casually doled out and so lacking in the drama of overt signs of
424 violent, sexual or emotional abuse, contribute strongly to pervasive feelings of fear. It has
425 been noted that they occur in tandem with more intense breaks in attachment, but they are
426 too important to overlook. The effects of subtle traumas are keenly felt and internalised as
21427 shame and unworthiness that can only be distracted from by a mixture of sweetness and
428 pain. The complex trauma treatment approach is designed to address the underlying effects
429 of relational distress; and it is relational distress that appears to lay the foundations of
430 bulimic symptomatology.
431 Bulimia is a complicated and often intractable condition and incidence is on the rise.
432 This research, however, indicates that it need not continue to imply chronic suffering. If we
433 begin viewing it as an outcome of complex trauma and treat it accordingly, we may bring
434 hope to the lives of those who become trapped in its relentless cycle.
435
436
437 Declarations
438 Ethics approval and consent to participate
439 Ethical approval for this research was granted by the Torrens University Australia Human
440 Research Ethics Committtee. HREC ref no: H3/18.
441
442 Consent for publication
443 Consent for publication was obtained from all participants prior to interview.
444
445 Availability of supporting data
446 Data is not publicly available due to the protection of confidentiality for participants, but in
447 parts may be shared by the corresponding author on reasonable request.
448
449 Competing interests
450 The authors declare that they have no competing interests.
22451 Funding
452 There was no external funding of the research.
453
454 Authors’ contributions
455 Authors’ contributions: The research was carried out in fulfilment of a PhD at Torrens
456 University Australia. The primary researcher was Dr Antonia Saunokonoko. The main
457 supervisor was Dr Michelle Mars and the assistant supervisor was Dr Werner Sattmann-
458 Frese.
459
460 Acknowledgements
461 Not applicable.
462
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