Externalizing an eating disorder is a therapeutic strategy. Jenni Schaefer’s book Life Without Ed, co-written by her therapist Thom Rutledge, popularized this strategy The book summarizes Jenni’s recovery from an eating disorder.
Jenni describes how in her treatment she learned to personify the eating disorder as “Ed,” an abusive boyfriend. As explained in the blurb 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.” The book details the various exercises she used in her recovery. For example, she created a formal “divorce decree” with the eating disorder and pushed back on him at every turn. In an Academy for Eating Disorders 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.”
What is Externalization?
This “externalization” strategy derives from narrative therapy. A key principle of narrative therapy is that the person is not the problem – instead, the problem is the problem. The problem is viewed as something with which the person is in a relationship, not as something that is part of the person. It follows then that the person can separate themselves from the problem and reduce its effects on them.
Family-based treatment (FBT) is the leading evidence-based treatment for teen eating disorders. FBT adopts narrative therapy’s externalization strategy in dealing with the eating disorder. The perspective taken by FBT clinicians is that the teen must be extricated from the eating disorder’s clutches.
When working with families, the FBT therapist encourages them to treat the eating disorder as an external force that has invaded the teen and hijacked their brain. Some families will even name the illness after a favorite villain such as “Voldemort” or refer to it as “the monster.” The therapist then rallies parents and other family members to unite against this common enemy to help their teen fend it off.
Many patients and family members can relate to this externalization strategy because the teen does appear to transform into a “different person” under the spell of the eating disorder, especially around mealtimes. This externalization allows families to reframe the situation. The teen does not want to limit their eating—instead, the eating disorder is an alien force that makes them restrict their eating.
Research on Externalization
Both Life Without Ed and FBT have given externalization popular traction. However, research has not definitively answered whether it is a helpful technique. While we do have research showing FBT to be highly effective, FBT includes so many elements it’s possible that it might work without the externalization component. In order to know for sure, we would need special research in the form of dismantling studies that test each individual element of a full treatment—to determine the role of externalization on the overall treatment outcome. There is one recent qualitative paper that studied the process of externalizing the eating disorder.
Advantages of Externalizing
What are some advantages of externalizing the eating disorder?
- It offers a convenient and relatable metaphor: “The eating disorder is possessing you.”
- It can make it easier to call out certain behaviors as problematic even if they do not feel troubling to the patient themselves.
- Experiencing the eating disorder as an unwelcome invader may help marshal the patient to fight back against it.
- Redirecting the anger of families and caregivers towards the eating disorder allows them to retain compassion for the patient.
- It puts everyone on the same team battling a common enemy: the eating disorder.
- It can help the patient become accountable for their own recovery by learning to rebel against and defy Ed.
Reasons you might not want to externalize the eating disorder
Some professionals worry that giving the eating disorder its own persona gives it too much power. They worry it might encourage patients to blame the eating disorder while absolving them of any responsibility for recovery. Some people dislike externalization and find it too trendy.
According to the qualitative paper by Voswinkel and colleagues (2021), patients interviewed expressed mixed perceptions about externalizing. Some people with eating disorders feel like the eating disorder is a part of them. Consequently, they feel they were not taken seriously or criticized by externalization. Many of the characteristics of patients with eating disorders—such as perfectionism—are actually personality traits that by themselves are not problematic. So by associating these characteristics with an external agent, there is a risk of inadvertently criticizing the patient. People with eating disorders may find the externalization technique dismissive or invalidating of their experience. They may become angry when their family members externalize the eating disorder.
So, Should You Externalize the Eating Disorder?
Clinicians and family members considering externalization should assess the potential risks and benefits of this technique. If you are a person with an eating disorder and this metaphor makes sense to you, you can learn more about the strategy by reading Life Without Ed. If you are a family member of a person with an eating disorder 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 some teens in recovery.
It is always a good idea to check with the person with the eating disorder about how they perceive externalizing. Perhaps you are supporting a person in recovery who dislikes your ascribing the eating disorder its own persona. In this case, you can refrain from talking about it in front of your loved one but still use it as a way to frame your own understanding of the situation.
Alternatives to Externalizing the Eating Disorder
Eating disorder expert Carolyn Costin, MA, MED, MFT suggests a similar but alternative strategy to externalization: think of the patient as having two aspects of their own self, a “healthy self” and an “eating disorder self.” Eating disorder researcher Kelly Vitousek, Ph.D. offers another option: abandon the metaphor altogether and explain these behaviors to the patient as symptoms of starvation. These alternatives to externalization might be preferable to some people with eating disorders.
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. These symptoms are often improved with proper nutrition and normalization of eating behaviors.
Get Help for an Eating Disorder in California
To learn more about supporting your family member with an eating disorder, explore contact EDTLA here.