Externalising the Eating Disorder

Eating disorders are ego-syntonic in nature, causing individuals to perceive their eating disorder as part of their personal identity.

Externalising the eating disorder is separating the person from the eating disorder and seeing it as an external influence (Voswinkel et al, 2021). This can be helpful because it emphasises that it is the eating disorder that is the problem, not the person living with it.

An eating disorder can be a very strong driving force that can cause a person to behave in ways that are not usual for them. This may involve secrecy and lying, and even aggression, frustration, and anger. This may also involve self-destructive behaviours that are seemingly irrational, such as a refusal to eat, purging, and compulsive exercise. This can be difficult to understand for both the person with the eating disorder and their loved ones.

Externalising the eating disorder involves speaking about ‘the eating disorder’, rather than speaking to the individual as if the eating disorder is part of them. Separating the person from the eating disorder can help you to see the eating disorder as having a separate voice and thinking pattern to the individual. This will help the individual to feel that the eating disorder is the problem and may provide relief that they are not thought of as the problem. This helps to remove feelings of blame, guilt, and shame, and means that the individual may be more open to confiding in you about what is happening for them.

If the eating disorder can be seen and addressed as separate from the person, it means that together you can stand and look at the problem. You can develop more of an understanding of the eating disorder and the way it functions whilst not judging the individual. This will help the individual to consider what they actually think the eating disorder is saying and will help them to begin to challenge it.

In fact, a study by Voswinkel et al (2021) found that the majority of participants described externalisation as helping them view Anorexia Nervosa (AN) as something separate to them. That although it was difficult in the short term, it was perceived as necessary for long term recovery, as it could help them recognise which thoughts and behaviours were evoked by AN. It was helpful for someone else to clarify for them what belonged to AN and what did not. Because an eating disorder is ego-syntonic, it was reported by the participants that externalising and blaming the eating disorder felt dismissive and invalidating at times, so it is important to keep this in mind when using this approach and continue to take a curious and non-judgemental stance.

When discussing treatment plans and goals, talk about the eating disorder as a 'thing' - an entity in itself - that can be controlling of the individual and their behaviours in some harmful ways. Be mindful not to blame the eating disorder for everything the person is doing, thinking, or feeling, but rather, take a curious stance to understand if the eating disorder is influencing these things. Some individuals like to name the eating disorder something else, such as Ed, it, Ana, or E.D., which helps promote that externalisation.

Examples of Externalising the Illness

• “How much of the time is the ‘eating disorder’ in control of what you’ve been eating?”

• “What does the ‘eating disorder’ tell you about yourself?”

• “We've spoken about the ways that the ‘eating disorder’ can seem like a best friend to you. I wonder if you can see any ways in which it is making life harder for you?"

• “It’s really hard when you know you need to stop exercising to get well, but the ‘eating disorder’ may be telling you the opposite.”

• “You said you don’t eat cheese anymore, do you think that may be the ‘eating disorder’ talking?”

Voswinkel, M. M., Rijkers, C., van Delden, J.J.M. van Elberg, A. A. (2021). Externalizing Your Eating Disorder: A Qualitative Interview Study. Journal of Eating Disorders, 9, 128 doi: 10.1186/s40337-021-00486-6