Experiences of externalisation in recovery from anorexia nervosa: a reflexive thematic analysis

Abstract

Background: Many individuals perceive anorexia nervosa (AN) as a part of their personal identity. Externalisation 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. Externalisation is used in NICE recommended treatments for AN, 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 can help and hinder recovery. Methods: This qualitative study used a reflexive thematic analysis. Thirteen adults with a current and/ or past diagnosis of AN participated in semi-structured interviews. Analysis: Participants described their experience of externalisation as a journey which is depicted by five themes. ‘Separation’ portrays the separation of the individual’s internal dialogue from the ‘self’. ‘Making sense of AN’ describes the experience of language and exercises used to separate AN. ‘A third entity in relationships’ illustrates the impact of externalisation on relationships. ‘A relationship with AN’ elucidates the use of externalisation to explore the function and effects of the individual’s relationship to AN. ‘Managing AN’ explains the experience of a continued relationship with the externalised AN entity post-treatment. Conclusions: The notion of separating one’s internal dialogue from one’s concept of self may initially be rejected. As the individual develops trust in the therapist, they may begin to realise two sides within them, the “healthy self” (HS) and the “anorexia voice” (AV). However, social-cultural discourses around eating contribute to ambiguity during the dichotomous categorisation of thoughts. Externalising practices were most helpful when led by the individual using their own experience-near language. Externalisation which did not permit the individual to feel seen as a person beyond AN was hindering to recovery. Therapists, treatment teams and family members should be cognisant of the emotional effects of language used to externalise AN. Future research should elicit an understanding of the experience of externalisation among a diverse sample of young people and families.