Should you externalize your (or your loved one's) eating disorder?

Who is "Ed" Anyway?

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Externalization of the eating disorder is a therapeutic technique popularized in the book Life Without Ed, by Jenni Schaefer and Thom Rutledge. In her recovery, which is summarized in the book, Jenni Schaefer personified the eating disorder as “Ed,” an abusive boyfriend. As Jenni explains on her website, “By thinking of her eating disorder as a unique personality separate from her own, [she] was able to break up with Ed once and for all.” In the book she and Thom (her therapist) describe the various exercises she used, including talking back to the eating disorder and creating a “divorce decree.” In an Academy for Eating Disorders (AED) tweetchat (2014) on the topic, Jenni Schaefer tweeted, “Ed could say whatever he wanted.

To be in recovery, I had to make the decision to disagree with and disobey him.”

The strategy itself, referred to as “externalizing” the eating disorder, stems from narrative therapy. A central tenet of narrative therapy is that the person is not the problem – rather, the problem is the problem. The person is in a relationship with the problem. Through externalization, the problem is viewed as being something that is affecting the person rather than being a part of the person.

Family based treatment (FBT), an evidence-based treatment for adolescent eating disorders, borrows the process of externalizing the eating disorder from narrative therapy. In FBT, clinicians work to separate the individual from the eating disorder. In consultation with the family, they use a metaphor to paint a picture of an external force having invaded the child and hijacked their brain. It is common to assign a name to the illness such as “the monster” or “Voldemort” and encourage parents to work together to help their child fight off the eating disorder.

For many patients and family members, externalizing the illness makes sense because the individual does appear to become a “different person” under the influence of the eating disorder. The externalization reframes the situation: rather than saying that the patient wants to restrict their eating, we say that the eating disorder is an alien force that makes them do this.

While externalization has gained popularity, research cannot answer definitively whether it is a helpful technique. We do have evidence on the efficacy of FBT, of which externalization is a key component, but FBT includes so many elements that for all we know FBT might work without it. We would need dismantling studies to determine the contribution of externalization to the overall treatment outcome; this is a low-ranking research priority.

Potential advantages of externalizing the eating disorder:

  • It offers an efficient and simple metaphor.
  • It may be helpful in separating patients from symptoms that are egosyntonic (meaning not bothersome to them).
  • It may help the patient to fight back against the eating disorder by seeing it as separate and alien from their self.

It may help families and caregivers direct their anger towards the eating disorder and as a result retain empathy for the sufferer.

  • It can put everyone on the same team fighting a common enemy.
  • It can help the patient be accountable for his or her own recovery by learning to disagree with and disobey Ed.

    Potential disadvantages of externalizing the eating disorder:

    • Some professionals worry that:
      • Giving the eating disorder its own persona gives the eating disorder too much power.
      • It might allow a patient to blame the eating disorder and not take responsibility for their recovery.
    • Externalization might reinforce dichotomous thinking and helplessness on the part of the patient.
    • This framing can seem to idealize the “true self” and absolves the patient of all responsibility.
    • Patients may:
      • Dislike the idea of separating the eating disorder as it feels like a part of them.
      • Find this technique dismissive or invalidating of their experience.
      • Be angry when their family members externalize the eating disorder.
    • Since many of the characteristics of patients with eating disorders are actually personality traits that are not in and of themselves problematic, there is a risk of inadvertently demonizing the patient
    • Some people find externalization – which is essentially only a metaphor –  too (for lack of a better word) “cutesy” and are put off as a result.

    So, should you do it?

    Clinicians and family members wanting to use externalization will benefit by considering the potential risks and benefits of using this strategy. If you are a person in recovery and this metaphor makes sense to you, you can learn more about the technique by reading Life Without Ed. If you are a family member of a person in recovery and/or a parent doing FBT, it can also be helpful to consider this as a strategy for talking about the eating disorder with your loved one. Life Without Ed is also good reading for parents and even adolescents in recovery.

    If you are supporting a person in recovery and he or she dislikes talking  about the eating disorder as an external force, then you can still use it for your own understanding while minimizing talking about it in front of your loved one.

    Similar but alternative strategies to externalize include the following. You can listen to the patient and use their words to refer to the eating disorder. An alternative strategy used by eating disorder expert Carolyn Costin, MA, MED, MFT is to think of the patient as having two aspects of their own self, a “healthy self” and an “eating disorder self.” Another option espoused by eating disorder researcher Kelly Vitousek, PHD is to abandon the metaphor altogether and explain these behaviors to the patient as symptoms of starvation. Any of these alternatives can similarly highlight for a patient his or her own ambivalence about recovery.

    Finally, it is important to emphasize that, regardless of the way an eating disorder is framed, behavioral change is critical for recovery.  Many of the symptoms and dangers of an eating disorder can be related to nutritional deficits and these symptoms are often improved with proper nutrition and normalization of eating behaviors. Medical supervision is usually recommended to manage recovery from an eating disorder.


    Academy for Eating Disorders tweetchat summary (2014) 

    National Eating Disorders Association Google hangout (February 18, 2014) 

    Ramey, Heather H., Tarulli, Donato, Fritters, Jan C., and Fis, Lianne (2009). A Sequential Analysis of Externalizing in Narrative Therapy With Children. Contemporary Family Therapy

    Schaefer, J. & Rutledge, T. (2004). Life Without Ed: How One Woman Declared Independence from Her Eating Disorder and How You Can Too.

    Vitousek, Kelly (2005). Workshop Outline: Alienating patients from the “Anorexic Self”:Externalizing and related strategies, Seventh International Conference on Eating Disorders London, April 6, 2005 

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