Externalisation in family‐based treatment of anorexia nervosa: The therapist's experience

Lonergan, Katie; Whyte, Aileen; Ryan, Christian

doi:10.1111/1467-6427.12380

Cited by 6 publications

(4 citation statements)

References 72 publications

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“…The clinical vignette that illustrates Phase 2 of our program is a good example of this type of work. Likewise, our time frame facilitates careful and modulated use of externalization over time, as illustrated in Phase 4 of our MFT program, as well as an increasingly insight‐oriented use of it (Lonergan et al, 2021), which targets specific features of ED (perfectionism, anxiety…) rather than the whole illness. Finally, the duration of our MFT program, as well as the diversity of illness durations and stages of recovery that generally characterize MFT groups, make it more feasible to adopt a longitudinal developmental perspective on those specific life cycle issues and risks that are at play when an illness such as AN exerts an inward pull on the family at a time when the outward pull of adolescence should prevail (Rolland, 1994).…”

Section: Discussionmentioning

confidence: 99%

Development and implementation of a relationship‐focused outpatient multifamily program for adolescent anorexia nervosa

Cook‐Darzens

Duclos

2022

Family Process

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Multifamily therapy (MFT) for adolescent eating disorders (ED) is anchored in systemic theory and family therapy, but two conceptual and practical paths have emerged from this common framework. The first one, called ED‐focused MFT, is centered on behavioral change and weight gain in the early stages of treatment, while the second, known as relationship‐focused MFT, is less directly focused on symptom improvement and more on family changes. Compared to ED‐focused MFT, validation of more relationship‐focused MFT models has been lagging behind although they are frequently implemented and practiced in Europe. The purpose of this article is to give more visibility to existing relationship‐focused MFT models by presenting an integrative, yet predominantly family‐oriented MFT program developed for adolescent anorexia nervosa (AN) (12 to 18 years) on the ED unit of a large pediatric hospital in France. After presenting the history and development of this relationship‐focused MFT program, including the challenges it encountered and its evaluation, we describe its rationale and objectives, then outline its course and content, giving illustrations of techniques and activities for each of the five phases of the program. Finally, we review the current status of this model, its advantages and limitations, and provide a critical appraisal of existing evidence and recommended future research directions.

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Section: Discussionmentioning

confidence: 99%

Development and implementation of a relationship‐focused outpatient multifamily program for adolescent anorexia nervosa

Cook‐Darzens

Duclos

2022

Family Process

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“…The LEAP component of treatment is a novel therapy developed to treat compulsive exercise in individuals with AN and integrated into each phase of the CBT-AN treatment [ 24 , 41 ]. It seeks to challenge the role of compulsive exercise as a maintaining factor of AN and promotes healthy beliefs and behaviours, utilising psychoeducation, cognitive restructuring, and behavioural experiments.…”

Section: Methodsmentioning

confidence: 99%

“…Externalisation is one therapeutic intervention that invites the person to re-story a sense of themselves through linguistically separating a person’s identity from the problem [ 25 , 39 , 40 ]. Externalisation has been popular in AN treatments, including externalisation of the illness in FBT [ 25 , 41 – 43 ]. Although intended to liberate the person from the illness identity, this practice has proven troubling for some individuals who [ 1 ] experience AN as both separate and a part of themselves [ 30 , 38 ] and [ 2 ] lose their voice when others assume their experience to be the voice of the ED [ 44 ].…”

Section: Introductionmentioning

confidence: 99%

Key-in-session identity negotiations in a first line treatment for adult anorexia nervosa

Heywood,

Conti,

Touyz

et al. 2024

J Eat Disord

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Background Exploration of client identity negotiations during treatment for Anorexia Nervosa (AN) is a relatively new area of research. Research suggests that difficulties with identity negotiations may present as a barrier to treatment. This study sought to explore individuals’ identity negotiations during therapy sessions using Compulsive Exercise Activity Therapy (LEAP) combined with Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN). Analysis focused on moments in therapy where individuals’ identities were dominated or defined by AN and where alternative identities could be generated. Method 40 in-session transcripts from sessions at early, mid and end points of the CBT-AN (with LEAP) treatment were qualitatively analysed for nine of the 78 participants in the original randomised control trial. Through a constructivist framework, thematic analysis was used to identify surface and latent meanings and discursive material participants used to negotiate their identities in the context of therapy sessions. Results Analysis of in-therapy transcripts generated two themes pertaining to identity negotiations: (1) troubled identities and (2) rebuilding identities and lives outside of AN. Early therapy sessions explored fragmented and AN dominated identities, including how AN was troubling to participants’ sense of self, contributed to conflicted identities, positioned them outside of normality, and was associated with isolated and othering identities. Within therapy sessions, participants engaged in a recursive process of shifting relationships with AN and themselves and building identities and lives outside of the AN identity. This included generating hopes for recovery and the future more frequently in mid- to late- therapy sessions. Conclusion Identity negotiations evident in the therapeutic conversations aligned with the key components of the CBT-AN intervention, including addressing (1) the characterisation of oneself as ‘an anorexic’ and (2) the diversification of roles and activities to broaden and enhance self-concepts. Future developments of therapeutic interventions for AN would benefit from greater consideration of ways to assist individuals to more comprehensively address problematic identities, including uncovering identities hidden by the AN identity and generating preferred identities. Trial Registration: Ethics approval was obtained at the time of the initial study and for this embedded research by the HREC at the Western Sydney University (HR777332).

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“…However, the association between therapeutic alliance and treatment outcome is signi cant for individuals with AN [32]), suggesting that the therapist-individual relationship is crucial in facilitating positive change. FBT/FT-AN therapists suggest that externalisation can support recovery when used in conjunction with other skills including listening, rapport building, effective timing of interventions, engaging with a family, understanding their relationship dynamics and knowledge of barriers to externalisation including problem awareness, age and illness duration [33].…”

Section: Anorexia Nervosamentioning

confidence: 99%

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

Cripps,

Serpell,

Pugh

2024

Preprint

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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.

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Externalisation in family‐based treatment of anorexia nervosa: The therapist's experience

Cited by 6 publications

References 72 publications

Development and implementation of a relationship‐focused outpatient multifamily program for adolescent anorexia nervosa

Development and implementation of a relationship‐focused outpatient multifamily program for adolescent anorexia nervosa

Key-in-session identity negotiations in a first line treatment for adult anorexia nervosa

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

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