Externalizing your eating disorder: a qualitative interview study

Abstract

Background Anorexia nervosa (AN) is a psychiatric disorder with an ego-syntonic nature, causing many patients to perceive their AN as part of their personal identity. Therefore, an important part of treatment is the externalization of the eating disorder, in order to help patients to perceive AN as an external influence. Studies on patient experiences of externalization in treatment for AN are sadly missing. The aims of this study were to investigate, first, patients’ perspectives on the relation between identity and anorexia nervosa (AN) and second, their experiences of an externalizing approach during treatment. Method A qualitative interview study was conducted including fourteen patients with AN in either Family Based Treatment, the Maudsley Model for Anorexia Nervosa Treatment for Adults, Specialist Supportive Clinical Management-Severe Enduring or Cognitive Behavioural Therapy-Enhanced. Results There are important differences in participants’ perceptions on how AN is related to identity. AN was perceived as part of identity, as alien or as a different side of the self. Patients’ experiences towards an externalizing approach were ambivalent. Externalization was considered helpful, whilst also evoking a negative response. Participants reported feeling as if all their behaviour was referred to as part of AN, which elicited feelings of not being taken seriously or being wrongfully accused of being dishonest. Conclusions First, there is considerable variation in the perceived relation between AN and identity. Second, an externalizing approach within treatment may lead to so called epistemic injustice. Awareness of these two facts is of importance for clinicians and the therapeutic relationship because that will help them to refrain from actions that can be perceived as epistemic injustice.

Involuntary treatment: A qualitative study from the perspectives of individuals with anorexia nervosa

“…The need to control one's eating features prominently in Fairburn et al.’s (1998) cognitive‐behavioral model of AN and emerges as a frequent theme in clinical work with those with AN. Despite this, individuals with AN can at times acknowledge that they are not, in fact, in control of their eating; rather, the ED is in control of them (Tan et al., 2003; Voswinkel et al., 2021). In the context of involuntary treatment, it may be useful to reframe patients' beliefs that they are “losing control” by conveying that the purpose of involuntary treatment is to take control away from the ED and (through involuntary treatment) give it to the treatment team in order to ultimately give the control back to the individual.…”

“…Externalization of the ED is used in approaches such as family‐based treatment (Lock & Le Grange, 2013) and can be useful in helping caregivers to not blame unwanted ED behavior on their child, but rather on the ED itself, and can aid patients in distinguishing between the healthy parts of themselves and the voice of the ED. However, it must be used carefully, as those with EDs can also experience it as being dismissive (Voswinkel et al., 2021), and both caregivers and providers could use externalization in a way that can make patients feel as if they are being reduced to their ED, regardless of their behavior and true intentions.…”

‘An extra fight I didn't ask for’: A qualitative survey exploring the impact of calories on menus for people with experience of eating disorders

“…This points to the way that individualization and neoliberal responsibilization shapes how people manage their ED recoveries. LaMarre and Rice (2016) noted: in an age of individual responsibilization, in which we are all expected to self-monitor and apply health teachings-not only do instructions about recovery come from those in power, but they also come through self-instruction as individuals search for, negotiate, and strive to enact "recovery" bodily practices (p. 2) This negotiation becomes apparent when we consider how participants appeared to be navigating health teachings about restraint and thinness, recovery teachings about freedom and removing the 'healthy self' from the 'ED voice' (Voswinkel et al, 2021), and counter-cultural movements such as anti-diet culture, intuitive eating and anti-weight stigma (Au & Cosh, 2022;Jovanovski & Jaeger, 2022). These tensions can be understood as situated in a culture which privileges selfresponsibilization in ED recovery.…”

Cognitive behaviour therapy for adolescents with eating disorders: An effective alternative to the disease-based treatments

“…The disease model postulates that the characteristics of the eating disorder are the result of a specific disease (i.e., anorexia nervosa, bulimia nervosa, or other eating disorders). Therefore, a key strategy of the treatment is the "externalization" of the eating disorders with the aim to help patients to perceive the illness as a separate entity form them (Voswinkel, Rijkers, van Delden, & van Elburg, 2021). The patients are considered not to be in control of their illness and, thus, they need the external control of parents, as in FBT (Dalle Grave, Eckhardt, Calugi, & Le Grange, 2019), and/or health professionals, as in multidisciplinary treatments eclectic for adolescents.…”