Background: Many individuals perceive Anorexia Nervosa (AN) as a part of their personal identity. Externalisation of the problem is a practice that is often taken up within NICE recommended treatments for AN. Dominant understandings of externalisation are that this practice involves making the "problem" a separate entity, external to the individual. It is an attitude taken by the client and family, stimulated by the therapist to build engagement with treatment and supportive relationships around the individual. However, there is a paucity of research exploring the therapeutic effects of this approach. This research aims to address this gap by exploring the role of externalisation in treatment for AN to elicit an understanding of how this practice is experienced including how it can help and hinder recovery.
Methods: Thirteen adults with a current and/or past diagnosis of AN participated in semi-structured interviews. This qualitative study used a reflexive thematic analysis.
Analysis: Participants described their experience of externalisation as a journey which is depicted by four main themes. 'Separating the AN from the self' reflects the tensions inherent in learning to distinguish between one's perceived sense of "self" and "the AN". 'Making sense of the AN' describes the experience of language forms used to separate the AN from the individual's identity. 'Feeling seen, or unseen as a person beyond the AN' illustrates the helpful and harmful effects of externalising practices on relationships. 'Navigating a complex relationship with the AN' depicts the effects of one-, versus two-way externalisation on the individual's relationship to AN.
Conclusions: The notion of separating one's internal dialogue from one's concept of self may initially be rejected by the individual experiencing AN. However, as the individual develops trust in the therapist and becomes socialised to common forms of externalising language, they may begin to realise two sides within them, a perceived "healthy self" and "the anorexia voice". However, social-cultural discourses around eating contribute to ambiguity during the differentiation between these two voices, thus elucidating the effects of an absence of problem deconstruction alongside externalisation within ED-focussed treatments. Externalising practices were most helpful when led by the individual using their own experience-near language and least helpful when they did not permit the individual to feel seen as a person beyond the AN. Therapists, treatment teams and family members should be cognisant of the emotional effects of language used to externalise AN. Importantly, they should ensure that externalisation is practiced within the spirit of narrative therapy from which it originates.
Keywords: Anorexia Nervosa; Anorexia voice; Eating disorder; Externalisation; Qualitative; Recovery; Thematic analysis.
This research explores the experiences of individuals with current and/ or past experience of anorexia nervosa (AN) who received NICE approved psychological therapies in which their eating disorder (ED) was separated from their identity through externalisation. Within these therapies, externalisation is a therapeutic practice that involves viewing AN as an external entity or illness that is separate from the identity of the individual who is experiencing AN. Participants described how it was initially difficult to accept that their thoughts, feelings and behaviours were influenced by something external to them. However, over time, the individual experiencing AN began to trust in this idea which was proposed to them throughout treatment. This perception of their experiences had both positive and negative effects on their recovery. This research suggests that individuals experiencing AN, their therapists, treatment teams and family members should be curious about the emotional effects of the language forms used to separate AN from the person’s identity. Language which empowered individuals in relation to their eating difficulties and which permitted individuals to feel seen, heard, and validated as a person beyond AN supported their recovery. The findings underpin the importance of individual-led externalisation and thus, practicing externalisation with adherence to the core narrative therapy principles which underlie this therapeutic practice. In doing so, externalisation may be used most helpfully to support recovery from AN.
© 2024. The Author(s).