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!
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