Externalizing your eating disorder: a qualitative interview study

J Eat Disord. 2021 Oct 15;9(1):128. doi: 10.1186/s40337-021-00486-6.


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.

Keywords: Anorexia nervosa; Epistemic injustice; Externalization; Patient experience.

Plain language summary

Many patients with anorexia nervosa (AN) have the experience that their eating disorder is part of who they are. Therefore, in the treatment of AN, healthcare professionals try to make clear to patients that there is a distinction between who they are and their AN. Through labelling certain thoughts and behaviour as stemming from AN, healthcare professionals guide patients in recognizing what is AN and what is not. This process is called externalization. In this study, fourteen patients with AN were interviewed on their thoughts about the relation between their identity and their eating disorder, and their experiences of externalization of AN within treatment. What becomes clear in these interviews is that patients’ perceptions on the relation between AN and their identity varies greatly, from experiencing AN as part of who they are to AN as something completely alien to them. Externalization is sometimes experienced as helpful, yet at the same time patients felt as if all behaviour was labelled as part of AN, which made them feel as if they were wrongly accused of being dishonest or not taken seriously. For healthcare professionals it is important to know that these side effects may arise when externalizing AN in treatment.