If you kick around the eating disorder recovery/treatment/research community for a while, you’re bound to come across someone calling their eating disorder “Ed.” In both the popular and scholarly literature around eating disorders, this externalizing and personifying approach has come to be quite popular. At face value, it makes sense to attribute blame for what can be an extremely difficult and painful experience to something other than oneself; it might be easier to “fight for recovery” if you have something to fight against.
But is there any evidence for the helpfulness of externalizing eating disorders? Who is “Ed,” and does “he” (or “she”) hold meaning for most or all sufferers? How might treatment programs make use of this construct in helping to facilitate clients’ recovery?
I will preface this post with a few disclaimers: firstly, I found a lot of solace in personifying my eating disorder early on in treatment and into early recovery. Later, it came to irk me, because I felt that it seemed disingenuous to parse out elements of myself and try to do away with some of them while retaining others.
Additionally, I found “traditional” treatment (i.e. a multi-modal day hospital treatment program at a hospital using a combination of CBT, DBT, and adjunct therapies) to be incredibly helpful. This one is important to keep in mind, because while I can be critical of treatment programs at times, I also acknowledge (both anecdotally and based on my knowledge of the evidence in the area of treatment outcome studies) the great work that these programs can do and the incredible help that these programs provide for some clients.
Finally, when I stumbled across a literature on narrative therapy for eating disorders, I was quite enthusiastic about its potential, if a little bit unsure about whether it would help many individuals or just some who were frustrated with more traditional approaches. The ideas put forth by narrative therapists, including that we live and structure our lives around our stories (e.g. Madigan, 2010) are compelling to me, and as I progress through my research I find that participants’ stories really do have a lot to say about who they are (or at least who they are portraying to me, a researcher, in the moment of the telling).
With these things in mind, I’d like to explore some of the evidence and conjecture around narrative therapy. I’ll use a recent article by Scott, Hanstock & Patterson-Kane (2013) as a guide, pulling in some additional literature as well.
WHAT IS NARRATIVE THERAPY?
Narrative therapy for eating disorders emerged in the 1980s as an alternative approach to cognitive behavioural therapy and other similar approaches to treating eating disorders. Some key players in establishing narrative therapy include David Epston and Michael White. Narrative therapists work with clients, who create “anti-anorexia” and “anti-bulimia” stories; essentially, these stories depict a separation between the individual and the disorder, hopefully setting up space for sufferers to re-envision their relationship to their disorder.
By creating “anti-anorexia/anti-bulimia” scripts, individuals are positioned as active members of their treatment (White & Epston, 1990); they have control over the content and progression of the eating disorder story and the alternative story.
Narrative therapists recognize that though creating these stories can help individuals with eating disorders to construct a new story without the eating disorder, context is important. They recognize that individuals are not wholly controlled by their eating disorders; in fact there may be parts of the “eating disordered self” that they enjoy in other areas of their lives.
So, it is more complex than simply “writing the eating disorder out.” In this optic, individuals with eating disorders are actually quite masterful; they have found a way (even if it is maladaptive in the long term) to regulate the self that seems adaptive in the short term (Gremillion, 2003). Creating a “clean split” between the individual and the disorder might brush off the potential expression of self through the eating disorder that might be a part of an individual’s core identity (Brown, Weber & Ali, 2008).
Resultantly, some narrative therapy goes far beyond creating binaries, for example, of eating disordered/not eating disordered. Instead of making the (externalized) eating disorder just a “villain,” narrative therapists can work with clients to tease out elements of their identities that they prefer and hope to focus on (e.g. Saukko, 2009 in Malson & Burns, 2009).
WHAT IS THE EVIDENCE FOR NARRATIVE THERAPY?
To be honest, there is not a lot of “hard and fast” evidence for the use of narrative therapy. As Scott, Hanstock & Patterson-Kane point out, the majority of studies looking at the effectiveness of narrative therapy (including their own) have taken the form of case studies.
In 2006, Weber, Davis & McPhie published one of the few non-case study style articles on narrative therapy for eating disorders. The researchers conducted a small-scale study using narrative therapy in a group of women with long-course eating disorders with comorbid depression. Results included reduced eating disorder risk (measured using the Eating Disorder Inventory-3; EDI-3) and levels of depression.
Though case studies do not necessarily provide evidence for more than the single case they describe, existing case studies do provide some interesting examples of how narrative therapy can be used. For example, Scott, Hanstock & Patterson-Kane describe 10 (hour-long each) sessions over 12 weeks with a client diagnosed with eating disorder not otherwise specified. Over the course of the sessions, the authors describe working with the client to:
- Externalize the eating disorder, allowing the client to create distance between herself and the disorder and gain an onlooker stance as to the eating disorder’s “tactics”
- Explore the eating disorder’s “persona,” using a “reporter stance” to determine which values “belong” to the client and which “belong” to the eating disorder
- Develop an alternative story to bolster the client’s sense of self (not just with respect to eating, but in other areas of her life)
The authors evaluated progress through therapy in qualitative ways (i.e. by making notes on progress) and by having her complete the EDI at the 10th session. While not all scores were reduced (perfectionism subscale remained at an elevated clinical level), the client’s scores on over-control and asceticism were reduced. Notably, this was not meant to be the “end” of treatment; the authors note using these scale findings to guide future directions in therapy.
SO, WHY USE IT?
One of the primary reasons that therapists use narrative therapy is as a way to move away from more traditional approaches (like CBT), especially when these approaches have proven ineffective for clients. Criticisms of traditional approaches leveraged by narrative therapists include the idea that these treatments place undue emphasis on controlling eating and weight (for example, by using food diaries and weigh ins), and in some ways replicate the control of the eating disorder itself (e.g. Maisel, Epston & Borden, 2004).
Further, though some approaches to treating eating disorders have a better evidence base than others (for example, CBT-E and Maudsley model family based therapy), we still lack solid evidence pointing to one treatment as preferable across the board. As many eating disorder researchers (for example, Strober & Johnson, 2012) will point out, eating disorders are extraordinarily complex disorders requiring complex treatments that correspond with patient needs.
Narrative therapy might not work for everyone; some might find the process too “touchy-feely” or not find personifying their disorder to be at all helpful. However, as the growing body of case studies demonstrates, this approach might be promising for some. I wouldn’t go so far as to say that narrative therapy should be offered to all those for whom “traditional” treatment models don’t appear effective, but it could certainly hold promise for interested clients working with well-trained therapists.
SHADES OF NARRATIVE
Looking at other forms of treatment and the popular literature around eating disorders, shades of narrative therapy crop up in many places. Externalization is not exclusive to “pure” narrative therapy; often multi-modal treatment regimes will encourage patients to fight against “Ed.” Narrative therapy is also among the approaches that informed Maudsley model treatment, which has quite a strong evidence base, at least for younger adolescents with short-course disorders (Rhodes, Brown & Madden, 2009). Books like Jenni Schaefer’s “Life without Ed” and “Goodbye Ed, Hello Me” take this personifying approach to eating disorders, suggesting that having an eating disorder is like being in an abusive relationship.
So, readers, how do you feel about this approach? Have you found externalizing to be helpful, or too contrived? I’d love to hear your experiences!
References
Scott, N., Hanstock, T.L., & Patterson-Kane, L. (2013). Using narrative therapy to treat eating disorder not otherwise specified Clinical Case Studies, 12 (4), 307-321 : 10.1177/1534650113486184
My therapist didn’t use this approach, but I read “Life Without Ed” and found that viewpoint to be very helpful. Creating that distance between me and disorder allowed me to see that it wasn’t part of who I am as a person and therefore I could get rid of it.
I remember enjoying that book, too. I think it is really interesting how much the idea speaks to some people… like I wrote, I think that it has to do with the idea of having someone/something to fight against (that isn’t oneself). I guess the idea seems relatively intuitive, but it’s interesting to see how it does and does not help different people…
Interestingly, when I was with my therapist today, we were talking about ED. I initially, when she first brought up the idea of my disordered eating as something apart from me, thought it sounded like a lovely fairy tale concept. However, as we have delved further into my recovery process (I have been seeing her for about two years now), I can see the worth in externalizing ED. I can’t yet imagine my life without ED, but it is so helpful to me to read about the experiences of people who have broken free from him, and that gives me some hope.
It’s good to hear that reading about the experiences of people who have recovered has been helpful for you, and that you find externalization helpful! I can definitely see, too, how it might strike as a fairy tale concept, initially. Does your therapist work from a narrative standpoint? I find it really interesting how other treatment approaches have used externalization… seems to be a popular way of creating that divide between person/disordered thoughts.
It is been a long time since I saw the word “resultantly” used in a sentence. Anyway.
I never found it useful and still don’t find it useful but it is one of those things where I don’t even see the point in trying to establish some kind of evidence-base for it. It clearly helps a lot of people, and so they should totally go for it.
I always found narratives and vague analogies to be not only useless but extremely counterproductive. Indeed, I stopped going to groups at Sheena’s Place because it is a style that a particular facilitator seemed to employ a lot and it just left me feeling more aggravated after group.
In retrospect, it is not unlike my experiences with yoga; a yoga instructor (the two times I took a yoga class) would say things like, “Breathe to the back of your lungs, most people just breathe through the front of their lungs but try to breathe to the back of your lungs.” It makes no scientific sense and hence just irritates me.
But clearly it helps a lot of people; Schaefer’s books are popular, but they are absolutely not for me.
It is like animal therapy, or art therapy, or dance therapy, or something. If you like animals, sure, it might help. I don’t like animals, and I doubt it would work for me. Will it/does it help others? Absolutely.
For me, taking a pragmatic and practical approach that is in-line with the scientific evidence about the etiology of eating disorders was and continues to be the most helpful. My ED is not something outside of me, or separate from me, but it is also not all of me. The ED behaviours are not conducive to the life that I want to lead, and that motivated (and continues to motivate) me to get better.
There’s no AN-specific neuronal promoter. I can’t selectively GFP-label all the ED-specific neurons in my brain. So, thinking about it as some discrete entity that can be separate from the rest of me is just weird to me. I get it, and I get how it helps people, but I think I’ve taken too many neuroscience courses haha.
Sorry, my academic is showing…
Yeah, the evidence-based thing is tricky, I think. I wonder if the calls for evidence-based stem largely from a standpoint of healthcare economics- i.e. programs that aren’t “evidence-based” won’t get funded or covered by OHIP, or something? Just conjecture at this point as I haven’t looked into that but I’ve noticed there is a strong emphasis on the “evidence-based” across the healthcare provision spectrum. For better or for worse.
I have to say, I love your animal therapy analogy; I think you make a really good point about how things don’t work for everyone. Which is obviously a simple concept but seems hard to get through to some…
While I found the externalizing approach to be helpful say 6 years ago, I can’t get fully onside with it these days because, like you wrote: “My ED is not something outside of me, or separate from me, but it is also not all of me.” Interestingly, though I haven’t taken a single neuroscience course and probably never will, my reasons for moving away from the separation between individual/disorder seem quite similar- basically, I have trouble seeing where the lines would be between myself and my experiences, including but not limited to my eating disorder. Some of the narrative therapy approaches I agree more strongly with take a more nuanced approach, integrating this idea that we can’t really separate out different parts of ourselves (body/brain/etc.) and choose to fully distance ourselves from some of them.
Anyway, I hope that made sense…
For sure, I think the evidence-based thing comes from an economic perspective. I don’t have a problem with yoga therapy for EDs; I do have a problem if it is part of “treatment as usual” and you know, mandated in hospital program or something. Not the best use of our (very) limited resources.
You are a sum of your experiences (+ genetic predispositions of course). I find it much more helpful to view the ED as a maladaptive response to my inability to deal effectively with negative affect. It is not wholly negative, but in the long-term it is negative because it is discordant with the life I want to lead. That’s it. Pretty simply, really. I can get over using those maladaptive and learned responses without anthropomorphizing the whole thing. I wrote before on Tumblr that I don’t like that it sometimes has the risk of removing responsibility. I am not at fault for my ED; no one is, but to say “Ed” did it/said it/though it just seems SO weird to me, personally.
But I think that’s just my personality. I want to identify the problem and resolve it. I wonder if this is why I was never in denial about my ED, why I sought help myself, and why I’ve been fairly proactive about my recovery whenever I was able to be, realistically. It is probably also why my friends used to get annoyed at me because they’d complain to me and expect me to listen and sympathetic whereas I’d just be reciting their options for what they can to resolve the situation.
WordPress is having a weird moment; only part of the comment came through to my email! Odd.
The whole idea of “treatment as usual” sometimes seems difficult when it comes to EDs, to be honest. Because there are so few “evidence-based” practices for patients across the board, because people cycle in and out of treatment, and because sometimes not-evidence-based just means no one has done a replicable RCT (I think you’ve mentioned this last point in the past somewhere). Something to strive for, maybe, because it’s obviously important to invest provincial/federal and even personal resources in things that “will work.” But then, I guess one really never knows what will work until it does…
I think that those taking a more pragmatic, realist stance on their eating disorders and who see it more like you do could definitely take issue with externalization in particular. I think that as I’ve gotten older I’ve become more pragmatic, and maybe that’s why I started to complicate my buy-in to calling the eating disorder “ED” etc.
But then, n=1 so …
It is probably just the fact that I kept editing what I wrote and adding to it.
Is it that difficult though? I don’t think it is as difficult as we make it out to be. The problem lies so much more with economic and structural issues than with the actual treatments and the evidence for them. We spend tax dollars researching effective prevention programs; we spend money and time trying to figure out whether CBT or FBT is better in treating anorexia nervosa (or something like that, whichever); we all complain about the lack of evidence-based treatment but really, is that *really* the problem? Yeah, sure, it is a problem.
But a bigger problem reveals itself pretty quickly when you start thinking about: How many people have access to the care they need when they need it? How many people are on a wait list for a treatment program? How many people don’t have access (geographical or economical, among others) for services that are NOT covered by government healthcare? Should ED patients be paying out of pocket for a dietician? Really? I don’t think so.
I don’t know… it just seems like we are not willing to look at the bigger problem: capitalism in our health care system.
I wonder if there are predictors of what kinds of people would like the narrative therapy approach or find it useful. That’s really the key. We know some do and some don’t. It can be evidence-based for a subset of individuals, right?
I recently moved and thus changed treatment teams. I had been in DBT-based treatment, and I now see an e.d. therapist who uses a good amount of narrative therapy. (The creation of a narrative about what life might be like without an e.d. REALLY struck home for me.)
I am VERY glad that earlier in recovery I had DBT-based treatment. I think I needed that sort of skills-based therapy to help me develop tools to use as I recovered and stopped using my e.d. as my primary way to cope.
And, years later, I’m glad that I’m now seeing a narrative therapist. The work with her is MUCH more emotionally challenging for me, and I don’t think I could have coped with it early on in recovery. However, since I started seeing my narrative therapist – about 4 and a half months now – I’ve noticed a definite shift in how I feel about my eating disorder. While part of me still feels “loyal” to it, I also find myself truly wanting it out of my life, which is new for me. Before, I recognized that I couldn’t have it if I wanted to achieve my goals, but I still wanted it. I think now I’m starting to shift to no longer wanting it because my narrative therapist won’t let me ignore what life might be like without it.
Interesting to hear that you preferred narrative over DBT but that earlier on in recovery DBT was really helpful… makes me wonder if there could be or is some way of combining the two to really get the skills and tools for coping in other ways and then creating some distance from the eating disorder via story… just musings, obviously, but an interesting idea. I could definitely see narrative therapy being emotionally challenging, especially with a skilled practitioner. I think your comment illustrates how it’s more nuanced than simply “writing the eating disorder out”- I sounds like your therapist recognizes that there’s a kind of tension between holding on and letting go of different elements of your subjectivity and your eating disorder. Thanks for commenting and for your perspective!
Thanks for the feedback! I wouldn’t say that I prefer narrative over DBT. I think narrative is a better fit for where I am now, but I wouldn’t be where I am now without DBT. DBT was the only treatment that helped me sustain recovery behaviors long term, whereas other treatment methods had not achieved that.
I’ve found that the two naturally work together, at least in my case. I was in DBT-based treatment for so long that using the skills became automatic. I know how to self-soothe and manage the strong emotions that come up in narrative therapy because I naturally go to the DBT skills that I learned.
Yes, my therapist very much recognizes that narrative therapy for e.d.s is FAR more complex than simply writing a narrative of life without ed and suddenly realizing that’s what I want. I think this is crucial to doing narrative therapy for e.d.s in a way that is validating. My therapist recognizes that the ed and the experience of recovery ARE part of my story, and that’s okay. She honors the fact that my e.d. developed as a way of helping me survive devastating trauma. And, we’re working on developing a story and an identity that isn’t contingent up on having an active elements of an e.d. That said, I don’t know if I would be able to tolerate that idea if I didn’t have DBT skills that I trust to get me through!
Sorry my comment didn’t convey what I was hoping it would… I think I was still half asleep! Whoops! I was going for something along the lines of how you put it: “I think narrative is a better fit for where I am now, but I wouldn’t be where I am now without DBT.” This really makes a good point about how not only does one size not fit all in treatment, but one size does not even fit all for individuals as we progress through our trajectories.