Experiences of externalisation in recovery from anorexia nervosa: a reflexive thematic analysis

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Externalisation involves making the “problem” a separate entity, external to the individual. It is an attitude taken by the client and family, stimulated by the therapist to build engagement with treatment and supportive relationships around the individual. Externalisation is used in NICE recommended treatments for AN, however there is a paucity of research exploring the therapeutic effects of this approach. This research aims to address this gap by exploring the role of externalisation in treatment for AN to elicit an understanding of how this practice can help and hinder recovery. Methods : This qualitative study used a reflexive thematic analysis. Thirteen adults with a current and/ or past diagnosis of AN participated in semi-structured interviews. Analysis : Participants described their experience of externalisation as a journey which is depicted by five themes. ‘Separation’ portrays the separation of the individual’s internal dialogue from the ‘self’. ‘Making sense of AN’ describes the experience of language and exercises used to separate AN. ‘A third entity in relationships’ illustrates the impact of externalisation on relationships. ‘A relationship with AN’ elucidates the use of externalisation to explore the function and effects of the individual’s relationship to AN. ‘Managing AN’ explains the experience of a continued relationship with the externalised AN entity post-treatment. Conclusions : The notion of separating one’s internal dialogue from one’s concept of self may initially be rejected. As the individual develops trust in the therapist, they may begin to realise two sides within them, the “healthy self” (HS) and the “anorexia voice” (AV). However, social-cultural discourses around eating contribute to ambiguity during the dichotomous categorisation of thoughts. Externalising practices were most helpful when led by the individual using their own experience-near language. Externalisation which did not permit the individual to feel seen as a person beyond AN was hindering to recovery. Therapists, treatment teams and family members should be cognisant of the emotional effects of language used to externalise AN. Future research should elicit an understanding of the experience of externalisation among a diverse sample of young people and families. anorexia nervosa anorexia voice eating disorder voice externalisation recovery qualitative thematic analysis Plain English summary This research explores the experiences of individuals with current and/ or past experience of anorexia nervosa (AN) who received psychological therapies in which their eating disorder (ED) was separated from them through externalisation. Externalisation is a strategy used by therapists which involves viewing the ED as an external illness or entity to the individual. Participants described how it was initially difficult to accept that their thoughts, feelings and behaviours were influenced by something external to them. However, over time, individuals began to trust in this idea, which had both positive and negative effects on their recovery. This research suggests that individuals experiencing AN, their therapists, treatment teams and family members should be curious about the emotional effects of the language used to separate AN from the individual. Language which empowered individuals in relation to their eating difficulties and which helped individuals feel seen, heard, and validated as a person beyond AN supported their recovery. Background Anorexia Nervosa Anorexia Nervosa (AN) typically emerges during adolescence and tends towards a protracted course [ 1 ]; complete recovery is less likely the longer its duration [ 2 ]. Whilst treatment often succeeds at restoring weight, it is common for eating disorder (ED) cognitions and behaviours to persist [ 3 ]. Hence, further research to increase treatment efficacy is required. Externalisation in treatment for Anorexia Nervosa Externalisation is a practice used in NICE recommended treatments for AN [ 4 ]. It is a key tenet of Family Based Treatments [ 5 , 6 ], where family members are encouraged to separate the individual from AN - an ‘unwanted temporary illness’ which threatens to take their life [ 7 ]. Sometimes, AN is given a name and personified, creating a separate entity [ 8 ]. This approach is thought to preserve the relationships between the individual, their family and treatment team through reducing negative interaction, increasing compassion and united support [ 9 ]. Externalisation is also often used within individual treatments, including Cognitive Behavioural Therapy for Eating Disorders [ 10 ], Adolescent Focussed Psychotherapy [ 11 , 12 ], Maudsley Model of Anorexia Nervosa Treatment for Adults [ 13 ] and Focal Psychodynamic Therapy [ 14 ]. Externalisation as a practice from Narrative Therapy Externalisation is a language practice that originates from narrative therapy, developed by Michael White [ 15 ]. Narrative therapists see, hear and think about problems as being shaped and given meaning by narratives; problems are not hard realities that permanently define people, rather they are ‘problem stories’ through which people know themselves and are known by [ 16 ]. Hence, narrative therapy views problems as separate from people and assumes they have beliefs, competencies and commitments to assist them in changing their relationship with problems [ 17 ]. Externalisation is an attitude and orientation in conversations that requires a shift in the use of language to separate problems from people, to locate the problem in the problem, not within the person [ 18 ] This separation creates space for seeing the problem and thinking about it in new ways, opening possibility for developing a different relationship with ones’ self and one’s life stories [ 16 ]. The resulting effect, when externalising practices are careful and thoughtful, is that the individual feels less oppressed and more empowered in relation to the problem [ 18 ]. Externalising conversations usually proceed through a series of steps involving (1) the exploration of an experience-near name for the problem; (2) mapping, evaluating and reflecting on the problem’s influence; (3) identifying a preferred story through exploration of what is important to the individual; and subsequently, (4) creating foundations for action to move away from the problem’s influence and towards the preferred identity [ 18 ]. Research on externalisation of Anorexia Nervosa ‘Countering That Which Is Called Anorexia’ is one of the first narrative writings describing how externalisation can be used in treatment for AN [ 7 ]. The authors suggest that AN has a voice of its own, which acts as a ‘discursive parasite’. Further, that once separated from the person, they can be helped to find alternative discourse resources that assist them in gaining power to resist ‘the parasitic voice’. Therefore, externalisation of AN sometimes takes the form of an internal ‘anorexia voice’ [ 19 ]. However, research has questioned whether experiences of ED voices are a consequence of externalisation, or rather a discrete perceptual experience that individuals are not socialised into [ 20 ]. Whilst individuals can experience externalisation as a helpful aspect of treatment [ 21 ], research suggests that externalisation can have unintended effects. For instance, individuals can feel as though they are being wrongly accused of being dishonest, or not taken seriously when all their behaviour is labelled as part of AN [ 22 ]. Moreover, externalisation can be experienced as more or less helpful at different stages of treatment, depending on how individuals perceive the relation between their identity and AN [ 22 ]. For example, individuals who perceive AN as a core, valued part of their identify may feel invalidated when told to consider their own actions are merely ‘the anorexia’ [ 23 ]. Additionally, some parents feel that externalisation can exclude the individual’s voice in treatment, and when confined to an illness or other adversarial metaphor, place them and their family at risk of exhaustion and reduced agency [ 24 ]. Obstacles to recovery from AN are often located within the individual [ 25 , 26 , 27 , 28 , 29 , 30 , 31 ]. However, the association between therapeutic alliance and treatment outcome is significant for individuals with AN [ 32 ]), suggesting that the therapist-individual relationship is crucial in facilitating positive change. FBT/FT-AN therapists suggest that externalisation can support recovery when used in conjunction with other skills including listening, rapport building, effective timing of interventions, engaging with a family, understanding their relationship dynamics and knowledge of barriers to externalisation including problem awareness, age and illness duration [ 33 ]. Study aims and rationale Little is known about people’s lived experiences of externalisation. Whether externalisation helps or hinders may depend on how, when and by whom the practice is used, as well as the meaning given to what has been externalised, and the relationship people have to what is externalised. Whilst research has revealed negative counter-effects of externalisation within inpatient treatment [ 22 ], research exploring the perspective of individuals who have completed treatment(s) within a range of settings is lacking. Such research would provide insights into how externalisation helped and hindered across the entire recovery process, whilst also considering the influence of treatment context. This research aimed to address this gap by examining the experiences of adults who have and have not recovered from AN following evidenced-based treatment. We aimed to explore the following: How does externalisation effect people’s experience of treatment(s) for AN? How does externalisation effect peoples’ relationships with others? How and why does externalisation help and/or hinder the process of recovery? What role does externalisation play in relapse and staying well? Method Design A reflexive thematic analysis (RTA) [ 34 ] was used to derive themes to explain how externalisation can help and hinder recovery, allowing rich and descriptive insights into people’s experiences of externalisation during and beyond treatment(s) for AN to be obtained. Data collection The first author developed a semi-structured interview schedule utilising their personal and professional experiences, key literature and supervision. It focussed on: the overall experience of externalisation during treatment and its influence on relationships, engagement, change, recovery and relapse (see Additional file 1). Ethics This study received ethical approval from UCL Research Ethics Committee (approval number 22063/001). Prior to partaking in an interview, participants submitted their signed consent and were made aware of their right to withdraw, skip questions, and take breaks as required. Participants were debriefed and sent a support card following their interview. Recruitment Purposive sampling was used to identify UK residents aged 16 and above, with a current and/ or past diagnosis of AN for which they had completed one or more NICE recommended psychological treatments. Individuals did not meet criteria if they were not familiar with externalisation, they had received treatment over 5 years ago, they did not understand spoken or written English, or they were receiving inpatient treatment for AN at the time of data collection. Recruitment was conducted online through social media. Procedure Individuals who were interested in participating were provided a participant information sheet (PIS) and completed a study screening questionnaire. Eligible participants completed a pre-interview questionnaire which contained the consent form and Eating Disorder Examination Questionnaire (EDE-Q 6.0); a 28-item self-report measure of ED symptoms which generates a global score indicating ED severity [ 35 ]. Data collected through the screening questionnaire and pre-interview survey provided relevant background information to describe the sample (Table 1). Participants then took part in an online interview which lasted 40 to 90 minutes. Participants All participants were White British, aged between 20 to 39 (mean = 27.8) and identified as being ‘in recovery’, continuing to manage ED symptoms. The majority of participants reported to have initially received a diagnosis of AN within adolescence following which they had completed multiple treatments across inpatient and outpatient settings. The mean global EDE-Q score was 2.81 (range = 3.84, SD = 1.38), which sits between normative and clinical ranges [ 36 ]. Table 1. Participant Information Participant number (P) Age Gender Ethnicity Treatment(s) received Time since completed most recent treatment Current or past AN diagnosis Subjective recovery status 1 20 Female White British CBT-E Under 1 year Past In recovery 2 32 Female White British CBT-E, FBT, MANTRA, FPT 4 years Current In recovery 3 32 Female White British CBT-E, FPT 1 year Past In recovery 4 30 Female White British CBT-E 3 years Past In recovery 5 31 Female White British CBT-E, MANTRA, FPT Under 1 year Past In recovery 6 26 Male White British FBT, CBT-E, MANTRA 2 years Current In recovery 7 22 Female White British CBT-E 2 years Past In recovery 8 24 Female White British CBT-E, MANTRA 2 years Current In recovery 9 28 Female White British CBT-E Under 1 year Past In recovery 10 24 Female White British FT-AN, CBT-E, MANTRA Under 1 year Current In recovery 11 39 Female White British CBT-E, MANTRA In treatment Current In recovery 12 24 Female White British CBT-E 2 years Past In recovery 13 29 Female White British FBT, CBT-E, MANTRA Under 1 year Current In recovery CBT-E = Cognitive Behavioural Therapy for Eating Disorders FPT = Focal Psychodynamic Therapy MANTRA = Maudsley Model of Anorexia Nervosa Treatment for Adults FBT = Family Based Treatment FT-AN = Family Therapy for Anorexia Nervosa Data analysis The first-author (SC) employed an interpretive paradigm to RTA whereby they explored meanings, relations, nuances, contradictions and variations in people’s experiences whilst holding reflexive awareness of their own influence. Inductive and deductive approaches to coding and analysis were adopted; theoretical, research and experiential knowledge was drawn on to develop the research question and interview, however open coding was utilised to understand and emphasise participant meanings. SC watched each recorded interview whilst reading the corresponding transcript, noting reflections. They then worked systematically through the dataset whereby data segments were given analytically-meaningful descriptions. Subsequently, code labels were collated and data segments for each code were compiled. Shared patterns of meaning were then identified whereby clusters of codes sharing a core concept were compiled as themes. Thereafter, themes were assessed as to whether they highlighted the most salient patterns of meaning and were reviewed for their core concept and fit into the data’s overall story. Lastly, the themes were named and given a synopsis whereby analytic narrative and data extracts were weaved together to address the research question. Reflexivity Throughout the research, SC, the first author (I) reflected on my position as a white British heterosexual female trainee clinical psychologist with personal and professional experience of externalisation in treatments for AN. The process of keeping a reflexive journal and engaging in reflexive discussion in supervision helped to maintain clarity of thought about the topic and to hold an open, curious mind with an awareness of one’s own pre-conceived ideas. In line with the RTA approach, I utilised my subjectivity as a tool to delve deeper into the data and extrapolate meanings further. Results The themes and subthemes are shown in Table 2 . Table 2 Themes and subthemes developed during the analysis Theme Subtheme Separation It was my voice, it was me Separation of Anorexia from myself Are they my thoughts, or are they Anorexia’s? Making sense of Anorexia Externalising language Externalising exercises A third entity in relationships The therapeutic relationship Family and close others A relationship with Anorexia A complex relationship The shift in relationship to Anorexia Managing Anorexia A constant presence; to listen, or not to listen? Accountability and vulnerability Separation It was my voice, it was me Participants reflected on initially experiencing no separation between themselves and AN. Consequently, they did not feel understood when others used externalising language; this incongruence negatively impacted on their trust in treatment: “When it was first introduced, I didn't understand it, it affected the relationships because I felt like the people who were treating me didn't know what they were talking about, so I had no confidence in them” (P2). It was difficult to comprehend the notion of an external entity with its’ own voice exerting influence over them. Hence, externalisation initially evoked “scepticism”, “confusion”, and increased resistance. However, later on in recovery, participants realised “two sides” within them; one that wanted the “comfort” and “safety” of AN, and one that wanted a “normal life”: “I really couldn't get my head around it as a young person, but I think as an adult it definitely became more useful and a bit more appropriate. I started to find it helpful in terms of maybe seeing the two separate sides of me” (P5). Participants emphasised that others should “wait until the person is ready” to be “receptive” to externalising their experiences. Some highlighted the therapeutic benefit of the therapist initially exploring what led to the person being in treatment, as well as efforts to build rapport “with the person”. These conversations led to their “own conclusions” about the problem’s influence on their lives. Separation of Anorexia from myself In treatment, therapists would engage participants in conversations that differentiated between their “healthy self” and “the anorexia”: “We have discussions about whether I thought it was my healthy self or my eating disorder self that was making each decision” (P7). As treatment progressed, participants began to accept the notion that their thoughts, feelings and behaviours were under the influence of what felt like an “external force”. Engagement with this concept helped to promote engagement in treatment: “I now refer to it as ‘the’ eating disorder because it's not my problem… a problem with my personality, it's not a part of me. It’s just an illness. And as it’s not a part of me, I feel I can treat it better; that helped me to recover” (P1). The illness metaphor alleviated the perceived permanence of AN, deterring internalisation of the problem, which increased self-compassion, validation, and hope: “I needed to be reminded that I was a person beyond this. I'd forgotten…I didn't have many memories of who I was before anorexia, so it was very helpful in reminding me that I wasn't just an illness” (P2). The separation between self and AN enabled participants to “think more clearly” and access “a rational self”. They began to identify “anorexia thoughts” or “the anorexia voice” (both referred to hence forth as the AV) and separate these from thoughts perceived as generated by their “healthy self”: “It gave me a bit of direction because it gave me something specifically to challenge rather than it just being thoughts in my head” (P7). This separation contributed to a perception of one’s difficulties as becoming “more practical”, “less emotional” and “more manageable”, enabling some participants to become more attuned to their needs: “Once you separate, it makes it easier to not do the things that it’s telling me to do, because I feel like I can say no to it if it’s not my thought…like ‘I actually don't want to do that’” (P4). Are they my thoughts, or are they Anorexia’s? Participants emphasised how difficult it was to distinguish what belongs to them and what belongs to the externalised ED. In reference to this dilemma, participants highlighted the influence of dominant discourses such as diet culture. Consequently, thoughts which appeared “normal” within their social-cultural context were described as “grey areas” evoking uncertainty as to whether one’s perceived “healthy self” thoughts were actually the AV “in disguise”: “‘Don't eat that because if you eat too much sugar, you’ll get diabetes’…those kinds of thoughts were harder to externalise because they felt very normal” (P7). When the AV and “healthy self” were not easily differentiated, participants became caught up in their thoughts and were less able to tune into their needs. Moreover, some questioned what the externalised entity was and how they should relate to it: “I didn't really know what it [the AV] was…was it a separate being? or something in my brain that was telling me to do something?” (P6). Some participants continued to grapple with their conceptualisation of AN during recovery post treatment: “Even now I still think ‘How can I want to do something that I don't want to do?’ It’s a weird concept, even 10 years down the line” (P4). Making sense of the Anorexia Externalising language Participants reflected on the language used to make sense of their experiences in treatment. Some participants felt that combative language authorised a repositioning of themselves against the AV which they felt “neutral” language would not have. In this way, it felt “productive” to “fight against” the AV: “You could never really say anything neutral or that you're working with it in any way. It has to be ‘me against you’ meaning, otherwise you're not recovering” (P4). However, other participants highlighted the importance of “neutral language” for combative language evoked exhaustion, a sense of failure, and a “louder”, “more controlling” AV. Instead, they found it helpful to adopt a diffusing stance in response to the AV: “It [combative language] made the eating disorder louder. A more compassionate voice towards the eating disorder was better for me. If I talked back to it, it became more of a conflicting argument and made the eating disorder want more control” (P6). Participants emphasised how therapists and treatment teams should be attuned to the emotional effects of externalising language and to how their experience of the same language could be helpful or hindering at different stages of recovery. For example, one participant initially found it more helpful to “question their own thoughts”, rather than consider the influence of an external entity. However, the way that they related to their eating behaviour changed later on in their recovery: “At some point, it [externalisation] does make things slot together a bit. Rather than thinking ‘Oh, I’m crazy’, I now think ‘There was a force over me making me do that’. You start to think, ‘Oh, that makes a lot more sense’” (P4). Participants emphasised how crucial it is that therapists and treatment teams are led by the individual in order that externalising language has personal resonance. This approach was contrasted with the use of externalisation in a generalised, leading and assumptive manner. Hence, participants raised the importance of initially developing a shared understanding of the externalised concept: “I think that if he'd [therapist] gone straight in with, ‘Oh think of it as a separate person to yourself’, I just wouldn't have got on with it because…it would have felt weird to me. So it was a helpful process to discuss what that concept meant for me” (P7). Externalising exercises Externalising exercises, guided by the individual’s preferences, helped to create distance between the individual and AV. Letter writing was a difficult but “powerful” and validating task requiring “honesty”, “vulnerability” and “reflective” capacity. This process was helpful in supporting some participants to consider the functions and effects of the AV. However, others felt unable to engage in letter writing in a meaningful way because the exercise felt “trivial”, they did not have emotional or cognitive capacity, or they did not experience any separation between themselves and their internal dialogue around eating: “As much as I can say that there's one side of me that’s that and there’s one side of me that’s the other, and there are different paths of thought, it very much still feels like it was a part of me” (P8). Some participants felt that further abstracting the AV through visual imagery was not meaningful, whereas others felt that a visual representation gave them something “tangible” to communicate their experiences. However, it was essential that the image came from the individual rather than given to them. For instance, one participant was told to visualise an image of the AV which invalidated their distress: “‘Oh, just picture a goblin on your shoulders’, I feel like you don't understand. You have no idea how intense this is” (P5). In contrast, being asked to draw their experience of the AV helped participants to express themselves in a way which enhanced therapists’ perceived understanding: “I would imagine that the eating disorder thoughts were coming from that person [maleficent]. It helps me to separate it and to realise what was that voice and what was my own healthy voice. It helped her to see what I was imagining when I was thinking about the voice” (P9). Letter writing to AN as a friend and enemy, and to ones’ future self, as well as drawing AN were considered by some participants to be helpful at the time, however they did not feel the need to repeat these exercises. Instead, what helped to sustain recovery was continued daily management of their internal dialogue which they had practiced through role play, chair work or externalising conversations. A third entity in relationships The therapeutic relationship Participants described ambivalence about treatment. Feeling ‘understood”, “seen as a person” and experiencing “connection” were significant in building trust in the therapist and treatment team, and in turn, in an externalised conceptualisation of their internal experiences: “I trust my therapist as a person. When I started to do it [externalisation], it was somebody that was consistent in my treatment. Being understood was definitely a big part of it. She seemed to understand exactly what was going on in my head and so because she understood it so well, it made me realise ‘Oh, I see, this is anorexia’” (P9). Externalisation provided a “framework” and “common ground” to build a collaborative relationship, permitting the individual and therapist to stand together “on the same team” against the AV. Experiencing the therapist relate to them as a person beyond AN through the use of externalising language had a positive impact on participants’ sense of self and instilled hope: “It [externalisation] allows me to see myself as a person and not the eating disorder. That made me feel that she [therapist] believed that I could get rid of it as well. Seeing that someone else sees that pushes you forward” (P12). However, some participants discussed that therapists should be careful not to “over externalise” their experiences as they perceived the AV to be external but also “a part of them”. Some participants described a demeaning experience within inpatient settings whereby externalising language was used in a way which contributed to them feeling overlooked and de-valued as a person: “Staff on the ward need to use it a lot less because the result is you feel belittled. It really annoyed me. If I didn't like a certain food, […] and the nurses would say ‘that's your eating disorder talking’ (P13)”. Further, it was unhelpful for therapists and treatment teams to take an “aggressive”, “controlling” or “forceful” stance during externalising conversations as they evoked heightened emotions and caused participants to retreat into the ED: “When people try and enforce things on me, things get a lot harder for them because I dig my heels in, and this is probably where I switch into anorexia mode” (P11). It was more helpful for the therapist to use externalisation in a “subtle”, sensitive manner through engaging participants in conversations which explored the influence of AN on their lives, whilst acknowledging who they are as a person and the complexity of their relationship with the AV. In the context of a positive therapeutic relationship, participants began to replace trust in the AV with trust in their therapist: “I started to hear my therapists’ voice there as well saying what I should…what is the healthy response? I think as I started to trust her more, I started to listen to the anorexia voice less” (P9). Family and close others Most participants conveyed how others’ use of externalising language early on in their recovery could cause conflict, disconnection and distance in their relationships because they felt misunderstood and frustrated: “When I was still very unwell, it made me feel very alone and isolated because no one was understanding me and what was going on for me in my head. It used to really make me cross when my mum would say, ‘That's anorexia talking’ because I didn't know that that was the anorexia talking” (P2). However later on, some participants felt that the conceptualisation of AN as an external illness or entity helped them to explain their experiences to family and close others in a way that increased their empathic understanding. However, significant to feeling understood was that family and close others used the same language as participants and that they were sensitive to the functions of the externalised AN. One participant related their family’s difficulty engaging in family therapy to their family’s understanding of AN: “They very much saw it as ‘(participant’s name’ is the one that’s ill or she’s got this person on her shoulder’ but in that sense, it didn't help them to be more open to seeing it as a systemic issue” (P13). It was important that family and close others understood the influence of AN on participants’ thoughts, feelings and behaviours. Some participants felt that family and close others struggled to grasp an externalised conceptualisation of their difficulties and that this impacted on their containment of emotion and led to relational ruptures. Other participants explained how viewing the AV as an external force helped to alleviate relational strain through supporting family and close others to manage difficult emotions, and reducing their own shame and guilt related to the impact of their difficulties on others: “It makes it easier for family and friends to understand that it's not you that's behaving in that way, you're not choosing to behave in the way that you are. Cause that's what a lot of people think about eating disorders - that it's a choice to do what you do” (P3). However, it was unhelpful when family and close others attributed all of their communication to “the eating disorder”, or when they used language which evoked feelings of failure and distress. One participant explained how their friends’ use of adversarial metaphors contributed to their withdrawal from the relationship and their retreat into the ED: “When I'm hearing it from my therapist, it's calm and reassuring. But with my friends, it's forceful…it's completely different, and that puts me more on edge. It makes me feel more of a failure if things don't go right” (P11). A relationship with Anorexia A complex relationship Most participants explained that externalisation “was not the solution” as they continued to feel controlled by the AV. Some participants felt confronted and overwhelmed by their relationship to the AV when their experiences were externalised: “I despised it [AN]. When it wasn’t a part of me, I still to some extent, felt like it was a part of my life, and then obviously it meant there was another…problem…to deal with” (P1). Some participants described how externalisation contributed to them feeling that “control” or “a piece of them” was being taken away. In recovery, participants reflected on missing the “protective” functions of their relationship with the AV during times of difficult emotion. Therefore, emphasis was placed on “not trusting” the AV. Some participants questioned whether externalisation contributed to their attachment to the AV. One participant at an earlier stage of recovery described fear and anticipatory loss in their relationship to the externalised AN: “By externalising it, am I going to go through the grief period of loss because it's been a part of me for so long, and now that we are separating it and I'm moving away from it, well that’s the idea. Is that then going to kick off another relapse? Am I gonna be lost without it and want it back?” (P11). The importance of exploring and understanding the development and function of the individual’s relationship with the AV was emphasised. This served to reduce AN’s “bargaining power”, increase compassionate self-understanding and self-confidence in relation to the AV: “Rather than me deciding to have it in my life, I’ve looked at it as a separate being that's tried to intervene and interrupt things. Therapy allowed me to become more self-aware, but also understand why the eating disorder’s there in the first place” (P6). The shift in relationship to Anorexia Externalisation helped to increase hope through creating space for participants to consider “what they truly wanted” in life. The separation made it easier to visualise the “freedoms” that may be experienced without the AV’s influence. However, losing this relationship felt “daunting” because participants did not know who they were without it. Consequently, externalising conversations which were focussed on “strengthening” one’s “healthy self” were more empowering than solely focusing on eradicating AN. Accordingly, externalising conversations which facilitated reflection on personal values and aspirations helped participants to become more in touch with themselves, which in turn harnessed strength and determination to resist the AV: “Exploring my values as a person was really helpful in strengthening my own identity and helping me to externalise the anorexia voice because anorexic values are not my values, so why am I listening to it” (P11). Participants accentuated the significance of experiencing a sense of “worth” and “purpose” in their lives in order to feel willing to detach themselves from the AV. What helped participants to stay well was reminding themselves of the impact that AN had on their lives, and their prioritisation of important relationships and aspects of life over their relationship with the AV: “I know it can ruin marriages, friendships…it's really powerful. Thinking of it as a separate thing, I can think ‘Well, you're not gonna ruin my marriage’, ‘You're not gonna ruin my career’” (P4). Managing Anorexia A constant presence; to listen, or not to listen? Participants continued to feel in relationship with the AV post-treatment and weight-restoration. However, maintaining a sense of distance between self and the AV enabled participants to minimise its influence: “Being able to separate the two voices is one of the things that has helped me to stay well because I can say, ‘Okay, I'm not listening to... that’s the eating disorder voice’” (P8). Hence, externalisation enabled participants to live “a normal life” alongside the AV: “It's been an ongoing cycle that I've been in all my life. So, it's about managing my illness, allowing me to still do the things that I have to do” (P11). Participants acknowledged how easily they could “slip back” “under the spell” of the AV. Understanding when and how it tried to intervene during times of vulnerability was crucial in staying well: “I know that I've got something that people don't have that has the potential to destroy me and my sanity, or I can try to be stronger than it and do what I can to work against it” (P4). Some participants attributed belief that they “would never fully recover” to their “personality”, “genetics” and/or “brain structure”. However, externalisation fostered a sense of “choice” over whether they allow AN to be a part of their life: “If it's part of you, as long as you exist, it's going to exist as well. But thinking of it as something that’s separate makes me feel like it doesn't have to be there all the time. I feel I can carry on life without it” (P3). Relapse was conceptualised as “listening to the voice again”; choosing not to listen to the AV was crucial in reducing this risk: “It's almost like another voice that I'm trying to just leave behind or ignore. And the more you ignore it, the better you get at it” (P4). Accountability and vulnerability Participants expressed difficulty taking accountability through a tendency to blame their actions on a “third person”. Some participants conveyed how externalisation could give, but also take their “power” because the external entity became an “oppressive”, “omniscient figure” that was “impossible to stand against”. These participants considered whether it would be helpful to use language which evoked less fear: “…tread carefully not to overdo it so it becomes an invincible, powerful thing that becomes an excuse…you're like, well, I don't have control because it's actually not me that…the eating disorder is telling me this so therefore, I'm not going to eat” (P13). One participant discussed how her husband did not use externalising language and spoke to her directly about “making the right decisions”. Being spoken to as though she had authority over her eating behaviour empowered her to sustain recovery: “You don’t have to be accountable for your actions when you have a…when it’s something you want to do in secret and you've got someone to blame, it goes hand in hand. Him holding me accountable for my own actions stops either of us blaming it on a third party” (P4). Participants experienced shame, guilt and fear of disappointing their therapist when they had “given in to the voice”. However, externalisation helped to mitigate difficult feelings in the therapeutic relationship as they could “blame” their actions on “the eating disorder”. Sharing one’s internal experiences with others could feel exposing and unsafe, however talking about the influence of an external entity provided a way of communicating which required less vulnerability, making interactions with their therapist feel less intense, attacking and threatening. Some conveyed how talking about a “practical” “manifestation” helped to keep distance in the therapeutic relationship: “It’s kind of ‘It's happening over there’…So it's more about keeping someone else at arm's length” (P5). Discussion Participants described a journey in terms of their experience of externalisation in recovery from AN. This journey is depicted through each main theme which is discussed in relation to theory, research and clinical implications. Making sense of the externalised AN entity was an ambiguous process; participants questioned whether the AV was “a separate being”, “a part of themselves”, or “something in their brain”. This finding is consistent with research which demonstrates that AN is difficult for individuals to make sense of, with some individuals holding dual concepts of AN as both a part of themselves and as separate from their identity [ 19 ]. The findings provide further insight by illustrating how an externalised conceptualisation of ones’ internal dialogue can be initially difficult to comprehend. However, through the use of externalising language throughout treatment, participants began to engage with the notion of an internal “anorexia voice” which was to some extent split from the self. Over time and in the context of positive therapeutic relationships, engagement with this concept aided engagement in treatment, suggesting that externalisation is an important component of treatment for AN. Nevertheless, the findings provide insight into the complexity of the self in relation to the AV. Dialogical Self Theory is based on theories of self-multiplicity and assumes that the mind contains multiple ‘I- positions’ which can agree or oppose one another [ 37 ].The internal dialogue between the different positions is important for the development and maintenance of personal identity [ 38 ]. The multi-voiced self can become dysfunctional if the person has a limited number of self-positions, they are not aware of other positions, or they are aware of competing positions but are not able to reach an overarching point of view to reveal a new position [ 38 ]. From this perspective, the externalised AN (the AV) is one I-position and ED recovery is thought to be related to changes in the dialogical self, such as the strengthening of adaptive internal voices to counteract the AV [ 39 ].The findings illustrate how externalisation can help individuals to obtain distance from the AV, as well as access and strengthen an alternative I-position through separating the AV from a ‘healthy self’ which is nurtured to reduce the AVs influence. The findings are consistent with research demonstrating that at the onset of AN, individuals experience the I-position taken up by AN as positive and functional, however, as the ED progresses, individuals perceive the AV to be a controlling, critical, dominant and bullying external force [ 40 , 41 , 42 , 43 , 44 ]. The findings demonstrate how externalisation can support this shift in perspective by facilitating the individual’s reflection on the effects of the AV on their lives. Nonetheless, dominant diet-related discourses made it difficult for participants to differentiate between the healthy self and AV within their internal dialogue. Hence, supporting individuals to navigate the impact of dominant diet-related discourses when externalising AN may positively impact on people’s recovery. The findings underscore the importance of being individual-led when making sense of the AV. The intended effects of externalisation are diminished in the absence of a context in which the client is viewed as the expert on their life [ 45 ]. Hence, curiosity and willingness to ask questions to which the therapist does not know the answer are essential narrative therapy principles that underpin personally meaningful externalising conversations [ 17 ]. It was hindering to participant’s engagement when therapists and treatment teams enforced their own conceptualisations of AN onto the individual’s experiences. Hence, the findings accentuate the importance of using language that is congruent with the individual’s lived experience. This aligns with research which suggests that verbal synchrony between patients and their therapists contributes to positive treatment outcomes for AN [ 46 ]. Relatedly, the findings stress the importance of paying attention to individuality, for each participants’ experience of externalising practices was unique, and the same practice could be helpful or hindering at different stages of recovery. White asserts that therapists should continually consult with people about the perceived effects of their therapeutic work to ensure it remains meaningful, relevant and helpful [ 47 ]. Thus, regularly reviewing the effects of externalising practices with individuals in treatment may help to promote their positive effects. Participants appreciated the therapist taking up a compassionate, non-coercive and neutral stance during externalising conversations. Within the context of a previous high level of intervention for a persistent problem, rather than directly attempting to vanquish problems from people’s lives, it can be conducive to start with creating a reflective space through externalising conversations [ 18 ]. Participants valued externalising practices which acknowledged their attachment to AN over a ‘forceful’ approach in which the therapeutic focus was eradicating AN. This may be related to the bond between the individual and AV which is thought to explain ambivalence to change [ 41 , 48 ]. The latter studies advocate that therapists penetrate the tie between the individual and AV, whilst acknowledging the AV’s hold. White emphasises that early externalising conversations should not focus on encouraging the individual to engage in a struggle with the problem, but rather to develop a shared understanding of the problem’s character, operations, activities, and purpose [ 18 ]. White termed this ‘cool engagement’ and discussed how this posture can alleviate vulnerability and distress in relation to the voice of a problem, in comparison to a ‘hot engagement’ which promotes direct confrontation with it. Therefore, in contrast to taking a directive, confrontational approach to the AV, it may be beneficial for therapists to create a reflective space for the individual to explore, understand and revise their relationship with the AV. Participants expressed particular familiarity with combative language in treatments for AN. Metaphors are significant in externalising conversations; they are borrowed from discourses that contribute to specific understandings of life and identity and therefore shape an individual’s life and opportunities for action in relation to a problem [ 18 ]. Adversarial metaphors such as ‘fighting’ can contribute to feelings of defeat, failure, fatigue, overwhelm and reduced personal agency [ 18 ]. Furthermore, totalising the problem (dualistically defining it in totally negative terms) can obscure its broader context and invalidate what people give value to [ 18 ]. Hence, White did not intend for the position taken in relation to the problem to be either for, or against. Instead, the individual is invited to take a position that creates space for them to begin to reclaim their life from its effects. White suggests that to support individuals to revise their relationship to a problem, therapists should prioritise the use of metaphors which do not have adverse effects [ 18 ]. Accordingly, reclamation metaphors (e.g., ‘getting one’s life back from the problem’) should be prioritised over competition metaphors (e.g., ‘beating the problem’). Externalising the AV by commanding and gaining control over it is considered an important aspect of recovery [ 49 , 50 ] Jenkins & Ogden, 2012). Thus, it is common that metaphors privileged in treatment place people in a ‘battle’ or ‘fight’ ‘against AN’. However, ‘fighting’ the AV has been associated with more severe ED symptoms and distress [ 51 , 52 ]. Therefore, researchers have begun to question which ways of responding to the AV are helpful versus problematic, suggesting that ‘compassionate assertiveness’ may be a helpful response [ 39 ]. Combative language increased motivation to resist the AV for some, whereas for others, it activated their threat response, increasing the AVs dominance and the individuals’ submission. For these individuals, compassionate assertiveness and distancing from rather than arguing with the AV was more helpful. The findings are consistent with research in psychosis which suggests that aggressive counter-responding can stimulate threat-focused affective systems and heighten attention towards voices [ 53 , 54 ]. Difficulty tolerating negative emotion is a trigger for engaging with the AV [ 55 ]. Therefore, Kater discusses the therapeutic benefit of using Acceptance and Commitment Therapy (ACT), stating that using hard data to argue with ED thoughts is not helpful in managing obsessive thoughts and preoccupation [ 56 ]. The findings support the aforementioned studies and suggest that individuals who experience increased preoccupation and distress on attempting to “fight” the AV may find it more helpful to adopt a defusing stance. The findings indicate that externalising practices are most helpful when they allow an individual to feel “seen as a person”. Clients consider the care relationship to be a meaningful contributor to recovery [ 57 , 58 ]; feeling treated as a ‘whole person’ and having a ‘real relationship’ with the therapist are regarded as significant [ 59 ]. The findings demonstrate how helpful externalising practices can positively impact on an individual’s self-concept through enabling them to feel realised by their therapist. This finding is consistent with research which concluded that the individual’s visual of themselves is expanded through them feeling treated as a person who is more than AN by their therapist [ 60 ]. The findings support research which suggests that externalising the AV can provide a common language for therapist and client to work collaboratively despite the experience of ambivalence [ 61 ]. They also provide further insight by demonstrating that individuals need to develop trust in their therapist to become open to an externalised conceptualisation of their internal experiences. Individuals with AN deem a sense of connectedness between themselves and their therapist to be important for them to engage in adaptive relational processes, for instance self-disclosure [ 58 ]. Developing a shared understanding of the AV enabled participants to experience connection with their therapist, which in turn aided self-disclosure through mitigating the experience of shame. In the context of a trusting therapeutic relationship, individuals internalised their therapists’ voice and drew on it to respond to the AV. In narrative therapy, the therapists’ position taken in relation to their client, and the relationship between them are considered fundamental in bringing about positive change [ 45 ]. Therefore, externalisation is thought to be therapeutically powerful because it reflects the quality of a relationship, rather than a technique [ 45 ]. The findings illustrate how externalisation can aid the development of a positive therapeutic relationship in which the individual feels supported to revise their relationship with the AV within the containment of this alliance. Externalisation of AN as an external illness or entity helped to mitigate against family and close other’s perception that EDs are a “choice”, which in turn supported participants to maintain their important relationships. The findings are consistent with research demonstrating that caregivers can find it helpful to perceive AN as a separate entity as it enables them to attribute negative feelings to the ED rather than the individual [ 62 ]. However, they also provide new insight by demonstrating that when family and close others use language which is not congruent with the individuals’ understanding of their experience, or when it has adverse emotional effects, externalisation can negatively impact on relationships and recovery. White and Epston emphasised that the externalised problem definition should be mutually acceptable [ 15 ]. However, the FBT manual suggests picking a metaphor that works best for parents [ 5 , 6 ]. The findings suggest it is crucial that family and close others use the individual’s own experience-near language. Further, that they should be careful not to over-externalise the individual’s experiences as this may contribute to relational ruptures. The findings elucidate the risk that conceptualising AN as an external illness or third-entity might detract from psychological formulation which may contribute to family member understanding that the problem resides within the individual. Positive, helpful experiences of personal relationships are significant in AN recovery [ 63 ]. White advocated that the development of a shared understanding of the externalised problem within the context of the individual’s life experiences can assist their support network to be more containing and supportive of their needs and difficulties [ 45 ]. Participants reflected on the function of their relationship to the AV in terms of helping them to manage emotions that arose from life stressors, transitions, interpersonal relationships and sociocultural pressures. Hence, it is important that others’ conceptualisations of AN acknowledge the psychological, emotional and social-cultural factors which contribute to its development and maintenance. Whilst individuals feared the externalised AN and felt controlled by it, they also felt attached to it, daunted by the loss of it and missed it in recovery. Individuals describe their ED as ‘a life jacket’ that provides control, isolation, security, identity, and a tool for emotion regulation and avoidance [ 64 , 65 , 66 ]. Emphasising the negatives of AN without exploring its functions fails to acknowledge the meaning of ED behaviours, invalidates the individual, and neglects opportunity for finding alternative mechanisms through which needs can be met [ 23 ]. Exploring and understanding ones’ relationship with the AV through the use of externalising conversations and exercises which encouraged reflection on the AV’s function and effects enabled some participants to process their thoughts, feelings and experiences in relation to the AV and subsequently attempt to meet its perceived functions through alternative means. Therefore, externalising conversations which aid the development of self-understanding may help to reduce enmeshment with the AV. In contrast, using externalising language to emphasise attempts to vanquish AN without acknowledging its role within the individual’s life may serve to increase resistance. The findings are consistent with research which conceptualises EDs as attachment-relationships [ 67 ]. Research has questioned whether the individual-AV relationship is reflective of early attachments and interpersonal ways of relating [ 39 ]. It has been suggested that exploring the individual-AV relationship may help to resolve relational patterns and attachment-related issues which maintain AN [ 48 ]. The findings demonstrate how externalisation can aid this process by facilitating the development of a relational understanding of AN. For instance, letter writing and chair work opened space for participants to speak to the AN entity that they experienced themselves as being in relationship with. However, given the attachment themes and interpersonal patterns within participants’ narratives in relation to the AV and therapeutic relationship, it may be beneficial to utilise externalisation to explore the individual-AV relationship in the context of attachment-related issues and the clients’ interpersonal patterns. Emerging research demonstrates that the importance of using therapeutic approaches that address relational trauma with individuals who experience an AV [ 68 ]. Exploring the influence of early relationships and childhood experiences on the development of the AV may help to provide individuals with a greater sense of understanding in relation to their experience of AN. The narratives depict an interwoven relationship between vulnerability and accountability in relation to externalisation. They are consistent with research which depicts the experience of AN as being entrapped in a toxic, enmeshed relationship in which the self is shared with AN [ 41 , 69 ]. Internal ED dialogue reflecting an ‘abusive relationship’ predicts ED severity, suggesting that in order to enhance personal agency, the connection between negative appraisals of the ‘abused self’ and the abusive voice of the ED must be alleviated [ 70 ]. Some participants questioned whether externalising AN as a powerful third-entity gave the AV more authority and reduced their sense of agency. Referral to the ED as a separate entity, as though it has a life of its own is a common discursive phenomenon between healthcare professionals and service-users [ 71 ]. A ‘stronger AV’ (i.e., with higher levels of voice power, omnipotence, entrapment and defeated response) is associated with increased ED severity and duration [ 52 ]. Therefore, certain appraisals of the AV may hinder recovery by further exacerbating identification with an abused self, increasing distress and feelings of entrapment. Individuals with lived experience of AN regard empowerment consisting of taking responsibility and control leading to confidence, agency, resilience, autonomy and independence to be significant in recovery [ 72 ]. Therefore, therapists and treatment teams should be cautious of using language which empowers rather than disempowers individuals in relation to their experience of eating difficulties. Externalising practices which gave voice to participants’ values, purpose, commitments and aspirations versus those of the AV’s were significant in helping individuals to realise their life unlived due to AN. White’s rationale for externalising conversations was to make it possible for people to experience an identity that is separate from the problem; to open possibilities for the pursual of what is personally important [ 18 ]. In the course of AN, it can become increasingly difficult for people to find an alternative identity [ 22 ]. Individuals often comprehend recovery as desirable yet ‘unattainable’ and ‘unimaginable’ [ 73 ] as they fear losing a major part of their identity [ 74 ]. Hence, imparting hope can enhance therapeutic alliance and in turn improve outcomes [ 75 ]. The findings depict how externalising practices can increase hope by helping individuals to connect with a seemingly ‘unimaginable future self’ through not only feeling realised by others, but also by their selves. Hence, reflective practices that open space for an alternative narrative identity to develop and be thickened may increase people’s willingness to “let go” of AN. Lastly, distancing one’s self from the AV was a practice that participants used to minimise the AV’s influence on their life post-treatment and weight-restoration. Individuals who have been discharged from treatment after reaching a healthy weight describe AN recovery as an on-going process and emphasise the importance of psychological change (e.g., motivation and belief in the capacity to change) in sustaining recovery and managing relapse risk [ 76 ]. The findings suggest that externalisation can aid these processes of psychological change. For instance, externalisation provided participants with a sense of agency over how much influence they allowed the AV to have on their lives. Reflexivity I (the first author) approached this research with awareness of how my experiences which had shaped my views on the role of externalisation would influence my approach to this research. Prior to this study, I had observed how some individuals experienced vulnerability in relation to the entity that was externalised in treatment. In turn, I became curious as to whether the creation of an external entity through the use of language could increase fear and passivity in relation to one’s internal dialogue (the AV). Consequently, I approached data collection and analysis with interest in the emotional and relational effects of externalising practices. Accordingly, during the write-up of this research, focus was placed on the role of language in serving to empower versus disempower individuals in relation to eating difficulties. Within my reflexive journal, I acknowledged that I would need to be attuned to the language used by individual participants to describe their experiences. Adopting their choice of language enabled me to avoid imposing my own assumptions and to obtain an accurate understanding of participants’ views. I also noted that I may display particular interest in issues which personally resonated. To limit the impact of this, I was conscious of my role as a researcher and endeavoured to display equal interest in issues which did and did not have personal resonance. Whilst the negative impact of viewing AN as an external entity was present within my interpretation of the data (e.g., through reducing personal agency and accountability), I also recognised contradictions to this where some participants described how this conceptualisation had a positive impact on recovery (e.g., through alleviating the perceived permanence of the problem and enhancing motivation). I realised that peoples’ experiences of externalisation were varied and nuanced; further, that this would need to be reflected within the write up. Strengths, limitations and further research Holding ‘insider research’ status has both advantages and disadvantages [ 77 ]. An advantage relevant to this study was the potential for a greater level of trust between participants and researcher [ 77 ]. This was observable throughout the interview process whereby the first author perceived a strong connection with participants. Consequently, the interviews were long in duration due to the rich and in-depth conversations about participants’ experiences, resulting in high-quality data. However, the role of the insider-researcher in shaping knowledge production must be acknowledged rather than assuming that it offers a ‘correct’ way of viewing the population under study [ 78 , 79 ]. The involvement of service-users in the development of the interview schedule may have mitigated against the latter by eliciting a wider range of interview questions and findings. Nonetheless, in line with an RTA approach, the first-author actively followed up what they interpreted as being meaningful to participants [ 80 ]. Additionally, the final interview question asked participants if there was anything that had not been asked which they felt was important to share. It is hoped that this question permitted participants the opportunity to share experiences and views which were not guided by the researchers. Nevertheless, the experiential knowledge of living with a condition provides relevance and credibility to research [ 81 , 82 ]. Hence, future research focussed on externalisation would benefit from involving service-users in the development of the interview schedule. Moreover, the sample was largely homogeneous and individuals who identify as male, or non-binary, as well as individuals from ethnic backgrounds other than white-British are underrepresented, thus replicating issues within the ED research field [ 83 ]. Both gender and ethnicity influence the experience of AN [ 84 , 85 ]. Hence, eliciting insight into people’s experiences of externalisation in a more diverse sample may contribute to greater variation in the experience of externalisation. Additionally, all participants were aged 20 and above and identified as being ‘in recovery’. Thus, future research should explore the experience of externalisation in treatment for AN among children, young people and families. Lastly, exploring experiences of externalisation among individuals who identify as ‘fully recovered’ or ‘not recovered’ may shed light on how externalisation supports full remission from AN. Conclusions Externalisation is a popular intervention in treatments for AN. The findings underscore the importance of using externalisation in a person-centred manner, underpinned by narrative therapy principles, to ensure that language empowers rather than disempowers individuals. Accordingly, the findings highlight the importance of working with individuals to develop a psychologically informed understanding of their experiences of AN, as well as to strengthen an alternative narrative identity in line with their personal values. These findings may serve to prompt clinicians, treatment teams, and family members to be attuned to the individual’s emotions and experience of externalising language so they can support individuals with AN as helpfully as possible. Abbreviations UK: United Kingdom AN: Anorexia nervosa ED: Eating disorder AV: Anorexia voice/ thoughts FBT: Family based treatment for Anorexia nervosa FT-AN: Family therapy for Anorexia nervosa Author 1: SC Author 2: MP Author 3: LS Declarations Acknowledgements We would like to thank the participants who gave their time and emotional energy to this study. Author contributions SC lead on data collection, analysis, and writing this paper. MP and LS conceptualised and supervised the study, and edited the final manuscript. Funding This research was funded by the University College of London. Availability of data and materials The datasets generated and analysed during the current study are confidential due to the need to protect the privacy of participants. Ethics approval and consent to participate This study received ethical approval from the University College of London Research Ethics Committee (Approval number: 22063/001). Participants provided consent to participate via a pre-interview questionnaire administered online. Consent for publication All data has been anonymised and all participants provided written and verbal consent for the inclusion of their anonymised data to be included within this report. Competing interests The authors declare they have no competing interests. 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The link between negative emotions and eating disorder behaviour in patients with anorexia nervosa. European Eating Disorders Review. 2012; 20(6):451–60. https://doi.org/10.1002/erv.2183 Kater K. New pathways: Applying acceptance and commitment therapy to the treatment of eating disorders. In: Maine M, McGilley BH, Bunnell D, editors. Treatment of eating disorders: Bridging The Research-Practice Gap; 2010. p.163-80. Elsevier: Academic Press. https://doi.org/10.1016/B978-0-12-375668-8.10010-5 Karlsson S, Friberg W, Rask M, Tuvesson H. Patients’ experiences and perceptions of recovering from anorexia nervosa while having contact with psychiatric care: a literature review and narrative synthesis of qualitative studies. Issues in Mental Health Nursing. 2021;42(8):709-19. https://doi.org/10.1080/01612840.2020.1847222 Sheridan G, McArdle S. Exploring patients’ experiences of eating disorder treatment services from a motivational perspective. Qualitative Health Research. 2016;26(14):1988–97. https://doi.org/10.1177/1049732315591982 Rance N, Moller N, Clarke V. ‘Eating disorders are not about food, they’re about life’: Client perspectives on anorexia nervosa treatment. Journal of Health Psychology. 2015;22(5):582–94. https://doi.org/10.1177/1359105315609088 Conti J, Joyce C, Hay P, Meade T. “Finding my own identity”: a qualitative meta-synthesis of adult anorexia nervosa treatment experiences. BMC Psychology. 2020; 8(1):1-4. https://doi.org/10.1186/s40359-020-00476-4 Graham MR, Tierney S, Chisholm A, Fox JRE. Perceptions of the “anorexic voice”: A qualitative study of health care professionals. Clinical Psychology & Psychotherapy. 2019;26(6):707–16. https://doi.org/10.1002/cpp.2393 Fox JRE, Dean M, Whittlesea A. The experience of caring for or living with an individual with an eating disorder: A meta-synthesis of qualitative studies. Clinical Psychology & Psychotherapy. 2015;24(1):103–25. https://doi.org/10.1002/cpp.1984 Hay P, Cho K. A qualitative exploration of influences on the process of recovery from personal written accounts of people with anorexia nervosa. Women & Health. 2013;53(7):730–40. https://doi.org/10.1080/03630242.2013.821694 Eaton CM. Eating Disorder Recovery: A Metaethnography. Journal of the American Psychiatric Nurses Association. 2019;26(4):373–88. https://doi.org/10.1177/1078390319849106 Serpell L, Treasure J, Teasdale J, Sullivan V. Anorexia nervosa: friend or foe?. International Journal of Eating Disorders. 1999;25(2):177-86. https://doi.org/10.1002/(SICI)1098-108X(199903)25:23.0.CO;2-D Wildes JE, Ringham R, Marcus MD. Emotion avoidance in patients with anorexia nervosa: Initial test of a functional model. International Journal of Eating Disorders. 2010;43(5):398–404. https://doi.org/10.1002/eat.20730 Mantilla EF, Clinton D, Birgegård A. The unsafe haven: Eating disorders as attachment relationships. British Journal of Medical Psychology. 2018;92(3):379–93. https://doi.org/10.1111/papt.12184 Pugh M, Waller G, Esposito M. Childhood trauma, dissociation, and the internal eating disorder ‘voice’. Child Abuse & Neglect. 2018;86:197-205. https://doi.org/10.1016/j.chiabu.2018.10.005 Williams K, King J, Fox JRE. Sense of self and anorexia nervosa: A grounded theory. British Journal of Medical Psychology. 2015;89(2):211–28. https://doi.org/10.1111/papt.12068 Scott N, Hanstock TL, Thornton C. Dysfunctional self-talk associated with eating disorder severity and symptomatology. Journal of Eating Disorders. 2014;2(1):1-1. https://doi.org/10.1186/2050-2974-2-14 Wright K, Hacking S. An angel on my shoulder: a study of relationships between women with anorexia and healthcare professionals. Journal of Psychiatric and Mental Health Nursing. 2011;19(2):107–15. https://doi.org/10.1111/j.1365-2850.2011.01760.x Wetzler S, Hackmann C, Peryer G, Clayman K, Friedman DD, Saffran K, et al. A framework to conceptualize personal recovery from eating disorders: A systematic review and qualitative meta‐synthesis of perspectives from individuals with lived experience. International Journal of Eating Disorders. 2020;53(8):1188–203. https://doi.org/10.1002/eat.23260 Malson H, Bailey L, Clarke S, Treasure J, Anderson G, Kohn M. Un/imaginable future selves: A discourse analysis of in-patients’ talk about recovery from an ‘eating disorder.’ European Eating Disorders Review. 2010;19(1):25–36. https://doi.org/10.1002/erv.1011 Levine M. Communication challenges within eating disorders: What people say and what individuals hear. In: Jauregui-Lobera I, editor. Eating disorders: A paradigm of the biopsychosocial model of illness. Spain: IntechOpen. 2017;239-72. https://doi.org/10.5772/65305 Stiles‐Shields C, Bamford B, Touyz S, Grange DL, Hay P, Lacey H. Predictors of therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa. Journal of Eating Disorders. 2016;4(1):1-7. https://doi.org/10.1186/s40337-016-0102-6 Federici A, Kaplan AS. The patient’s account of relapse and recovery in anorexia nervosa: a qualitative study. European Eating Disorders Review. 2007;16(1):1–10. https://doi.org/10.1002/erv.813 Johnston MS. When madness meets madness: Insider reflections on doing mental health research. International Journal of Qualitative Methods. 2019;18. https://doi.org/10.1177/1609406919835356 Adkins L, May T, (ed.). Reflexivity and the Politics of Qualitative Research. In Qualitative Research in Action. London, Thousand Oaks and New Delhi: Sage Publications Ltd. 2002. https://doi.org/10.1080/09540261.2019.1593112 Taylor J. The intimate insider: Negotiating the ethics of friendship when doing insider research. Qualitative research. 2011;11(1):3-22. https://doi.org/10.1177/1468794110384447 Byrne D. A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Quality & quantity. 2022;56(3):1391-412. https://doi.org/10.1007/s11135-021-01182-y Lindenmeyer A, Hearnshaw H, Sturt J, Ormerod R, Aitchison G. Assessment of the benefits of user involvement in health research from the Warwick Diabetes Care Research User Group: a qualitative case study. Health Expectations. 2007;10(3):268-77. https://doi.org/10.1111/j.1369-7625.2007.00451.x Thompson J, Bissell P, Cooper C, Armitage CJ, Barber R. Credibility and the ‘professionalized’ lay expert: Reflections on the dilemmas and opportunities of public involvement in health research. Health. 2012;16(6):602-18. https://doi.org/10.1177/13634593124410 Halbeisen G, Brandt G, Paslakis G. A plea for diversity in eating disorders research. Frontiers in Psychiatry. 2022;13:820043. https://doi.org/10.3389/fpsyt.2022.820043 Acle A, Cook BJ, Siegfried N, Beasley T. Cultural considerations in the treatment of eating disorders among racial/ethnic minorities: A systematic review. Journal of Cross-Cultural Psychology. 2021;52(5):468-88. https://doi.org/10.1177/0022022121101766 Thapliyal P, Hay P, Conti J. Role of gender in the treatment experiences of people with an eating disorder: a metasynthesis. Journal of eating disorders. 2018;6(1):1-6. https://doi.org/10.1186/s40337-018-0207-1 Additional Declarations No competing interests reported. Supplementary Files Additionalfile1Interviewschedule.pdf Additional file 1. Interview schedule. Cite Share Download PDF Status: Published Journal Publication published 07 Oct, 2024 Read the published version in Journal of Eating Disorders → Version 1 posted Editorial decision: Revision requested 16 Mar, 2024 Reviews received at journal 04 Feb, 2024 Reviewers agreed at journal 04 Feb, 2024 Reviewers invited by journal 03 Feb, 2024 Submission checks completed at journal 31 Jan, 2024 Editor assigned by journal 31 Jan, 2024 First submitted to journal 28 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3906525","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":270256783,"identity":"afa02c44-e2ab-4065-b7d3-279fccd23258","order_by":0,"name":"Sophie Charlotte Cripps","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIie2RvWrDMBRGv2DwpMbrNQX7FRQM6RLyLBIGZ8kDZMjgKZ7a2UPfItBZEPCkpKtHZ+ncqXhKKzmFdoiajoXqLPo93E9XgMfzNwkh7BAMixmLgJEa5ux3SpHEJXBd+cYu4+qKklb3TdetkN5VN82xRyC3bd4prOfgWl1UuD4suNCYPO7Gi4whlE9tYQo1Ofi+vKzQckpyA0EBm96aMEZZmmChAn92BKutcjorcQ+S29oqJ7eC1irlWSEGnpm6UKONcgfTh4JEQ5M6sG/hIiH9wpV8yFnseL7tWNyvZylFe9Ox1TuLqvzYvb7Nk7EWjmRD98lOzAfxz03x00d+HbHQfcnj8Xj+NR8cNFXxGf7kiAAAAABJRU5ErkJggg==","orcid":"","institution":"University College of London","correspondingAuthor":true,"prefix":"","firstName":"Sophie","middleName":"Charlotte","lastName":"Cripps","suffix":""},{"id":270256784,"identity":"bf3e5989-9541-4ada-9af2-b52cc3d69adc","order_by":1,"name":"Lucy Serpell","email":"","orcid":"","institution":"University College of London","correspondingAuthor":false,"prefix":"","firstName":"Lucy","middleName":"","lastName":"Serpell","suffix":""},{"id":270256785,"identity":"4b35c00d-4e1c-4c81-b8fd-ca407490b140","order_by":2,"name":"Matthew Pugh","email":"","orcid":"","institution":"University College of London","correspondingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"","lastName":"Pugh","suffix":""}],"badges":[],"createdAt":"2024-01-28 18:14:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3906525/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3906525/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40337-024-01087-9","type":"published","date":"2024-10-07T15:57:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66597103,"identity":"f57fdac3-68eb-4b56-8858-3b0aa3bb8b28","added_by":"auto","created_at":"2024-10-14 16:07:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":837988,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3906525/v1/cc8b4239-0f29-4d12-a681-8cc4e04d7920.pdf"},{"id":50559571,"identity":"bb4573ec-0855-4c37-a53b-a90950dfd273","added_by":"auto","created_at":"2024-02-02 13:48:16","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":64190,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional file 1.\u003c/strong\u003e Interview schedule.\u003c/p\u003e","description":"","filename":"Additionalfile1Interviewschedule.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3906525/v1/7da3b40f0d998f97f244f297.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Experiences of externalisation in recovery from anorexia nervosa: a reflexive thematic analysis","fulltext":[{"header":"Plain English summary","content":"\u003cp\u003eThis research explores the experiences of individuals with current and/ or past experience of anorexia nervosa (AN) who received psychological therapies in which their eating disorder (ED) was separated from them through externalisation. Externalisation is a strategy used by therapists which involves viewing the ED as an external illness or entity to the individual. Participants described how it was initially difficult to accept that their thoughts, feelings and behaviours were influenced by something external to them. However, over time, individuals began to trust in this idea, which had both positive and negative effects on their recovery. This research suggests that individuals experiencing AN, their therapists, treatment teams and family members should be curious about the emotional effects of the language used to separate AN from the individual. Language which empowered individuals in relation to their eating difficulties and which helped individuals feel seen, heard, and validated as a person beyond AN supported their recovery.\u003c/p\u003e"},{"header":"Background","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eAnorexia Nervosa\u003c/h2\u003e \u003cp\u003eAnorexia Nervosa (AN) typically emerges during adolescence and tends towards a protracted course [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]; complete recovery is less likely the longer its duration [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Whilst treatment often succeeds at restoring weight, it is common for eating disorder (ED) cognitions and behaviours to persist [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Hence, further research to increase treatment efficacy is required.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eExternalisation in treatment for Anorexia Nervosa\u003c/h3\u003e\n\u003cp\u003eExternalisation is a practice used in NICE recommended treatments for AN [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It is a key tenet of Family Based Treatments [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], where family members are encouraged to separate the individual from AN - an \u0026lsquo;unwanted temporary illness\u0026rsquo; which threatens to take their life [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Sometimes, AN is given a name and personified, creating a separate entity [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This approach is thought to preserve the relationships between the individual, their family and treatment team through reducing negative interaction, increasing compassion and united support [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Externalisation is also often used within individual treatments, including Cognitive Behavioural Therapy for Eating Disorders [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], Adolescent Focussed Psychotherapy [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], Maudsley Model of Anorexia Nervosa Treatment for Adults [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and Focal Psychodynamic Therapy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eExternalisation as a practice from Narrative Therapy\u003c/h2\u003e \u003cp\u003eExternalisation is a language practice that originates from narrative therapy, developed by Michael White [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Narrative therapists see, hear and think about problems as being shaped and given meaning by narratives; problems are not hard realities that permanently define people, rather they are \u0026lsquo;problem stories\u0026rsquo; through which people know themselves and are known by [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Hence, narrative therapy views problems as separate from people and assumes they have beliefs, competencies and commitments to assist them in changing their relationship with problems [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExternalisation is an attitude and orientation in conversations that requires a shift in the use of language to separate problems from people, to locate the problem in the problem, not within the person [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] This separation creates space for seeing the problem and thinking about it in new ways, opening possibility for developing a different relationship with ones\u0026rsquo; self and one\u0026rsquo;s life stories [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The resulting effect, when externalising practices are careful and thoughtful, is that the individual feels less oppressed and more empowered in relation to the problem [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Externalising conversations usually proceed through a series of steps involving (1) the exploration of an experience-near name for the problem; (2) mapping, evaluating and reflecting on the problem\u0026rsquo;s influence; (3) identifying a preferred story through exploration of what is important to the individual; and subsequently, (4) creating foundations for action to move away from the problem\u0026rsquo;s influence and towards the preferred identity [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eResearch on externalisation of Anorexia Nervosa\u003c/h2\u003e \u003cp\u003e\u0026lsquo;Countering That Which Is Called Anorexia\u0026rsquo; is one of the first narrative writings describing how externalisation can be used in treatment for AN [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The authors suggest that AN has a voice of its own, which acts as a \u0026lsquo;discursive parasite\u0026rsquo;. Further, that once separated from the person, they can be helped to find alternative discourse resources that assist them in gaining power to resist \u0026lsquo;the parasitic voice\u0026rsquo;. Therefore, externalisation of AN sometimes takes the form of an internal \u0026lsquo;anorexia voice\u0026rsquo; [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, research has questioned whether experiences of ED voices are a consequence of externalisation, or rather a discrete perceptual experience that individuals are not socialised into [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhilst individuals can experience externalisation as a helpful aspect of treatment [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], research suggests that externalisation can have unintended effects. For instance, individuals can feel as though they are being wrongly accused of being dishonest, or not taken seriously when all their behaviour is labelled as part of AN [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Moreover, externalisation can be experienced as more or less helpful at different stages of treatment, depending on how individuals perceive the relation between their identity and AN [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. For example, individuals who perceive AN as a core, valued part of their identify may feel invalidated when told to consider their own actions are merely \u0026lsquo;the anorexia\u0026rsquo; [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Additionally, some parents feel that externalisation can exclude the individual\u0026rsquo;s voice in treatment, and when confined to an illness or other adversarial metaphor, place them and their family at risk of exhaustion and reduced agency [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eObstacles to recovery from AN are often located within the individual [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, the association between therapeutic alliance and treatment outcome is significant for individuals with AN [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]), suggesting that the therapist-individual relationship is crucial in facilitating positive change. FBT/FT-AN therapists suggest that externalisation can support recovery when used in conjunction with other skills including listening, rapport building, effective timing of interventions, engaging with a family, understanding their relationship dynamics and knowledge of barriers to externalisation including problem awareness, age and illness duration [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStudy aims and rationale\u003c/h2\u003e \u003cp\u003eLittle is known about people\u0026rsquo;s lived experiences of externalisation. Whether externalisation helps or hinders may depend on how, when and by whom the practice is used, as well as the meaning given to what has been externalised, and the relationship people have to what is externalised. Whilst research has revealed negative counter-effects of externalisation within inpatient treatment [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], research exploring the perspective of individuals who have completed treatment(s) within a range of settings is lacking. Such research would provide insights into how externalisation helped and hindered across the entire recovery process, whilst also considering the influence of treatment context. This research aimed to address this gap by examining the experiences of adults who have and have not recovered from AN following evidenced-based treatment. We aimed to explore the following:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eHow does externalisation effect people\u0026rsquo;s experience of treatment(s) for AN?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHow does externalisation effect peoples\u0026rsquo; relationships with others?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHow and why does externalisation help and/or hinder the process of recovery?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhat role does externalisation play in relapse and staying well?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eA reflexive thematic analysis (RTA) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] was used to derive themes to explain how externalisation can help and hinder recovery, allowing rich and descriptive insights into people\u0026rsquo;s experiences of externalisation during and beyond treatment(s) for AN to be obtained.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe first author developed a semi-structured interview schedule utilising their personal and professional experiences, key literature and supervision. It focussed on: the overall experience of externalisation during treatment and its influence on relationships, engagement, change, recovery and relapse (see Additional file 1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e This study received ethical approval from UCL Research Ethics Committee (approval number 22063/001). Prior to partaking in an interview, participants submitted their signed consent and were made aware of their right to withdraw, skip questions, and take breaks as required. Participants were debriefed and sent a support card following their interview.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment\u003c/h2\u003e \u003cp\u003ePurposive sampling was used to identify UK residents aged 16 and above, with a current and/ or past diagnosis of AN for which they had completed one or more NICE recommended psychological treatments. Individuals did not meet criteria if they were not familiar with externalisation, they had received treatment over 5 years ago, they did not understand spoken or written English, or they were receiving inpatient treatment for AN at the time of data collection. Recruitment was conducted online through social media.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eIndividuals who were interested in participating were provided a participant information sheet (PIS) and completed a study screening questionnaire. Eligible participants completed a pre-interview questionnaire which contained the consent form and Eating Disorder Examination Questionnaire (EDE-Q 6.0); a 28-item self-report measure of ED symptoms which generates a global score indicating ED severity [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Data collected through the screening questionnaire and pre-interview survey provided relevant background information to describe the sample (Table\u0026nbsp;1). Participants then took part in an online interview which lasted 40 to 90 minutes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eAll participants were White British, aged between 20 to 39 (mean\u0026thinsp;=\u0026thinsp;27.8) and identified as being \u0026lsquo;in recovery\u0026rsquo;, continuing to manage ED symptoms. The majority of participants reported to have initially received a diagnosis of AN within adolescence following which they had completed multiple treatments across inpatient and outpatient settings. The mean global EDE-Q score was 2.81 (range\u0026thinsp;=\u0026thinsp;3.84, SD\u0026thinsp;=\u0026thinsp;1.38), which sits between normative and clinical ranges [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;1. \u003c/p\u003e \u003cp\u003e\u003cem\u003eParticipant Information\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParticipant number (P)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eTreatment(s) received\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eTime since completed most recent treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eCurrent or past AN diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eSubjective recovery status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCBT-E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCBT-E, FBT, MANTRA, FPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCBT-E, FPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCBT-E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCBT-E, MANTRA, FPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFBT, CBT-E, MANTRA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCBT-E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCBT-E, MANTRA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCBT-E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFT-AN, CBT-E, MANTRA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCBT-E, MANTRA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIn treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCBT-E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFBT, CBT-E, MANTRA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eCBT-E\u0026thinsp;=\u0026thinsp;Cognitive Behavioural Therapy for Eating Disorders\u003c/p\u003e \u003cp\u003eFPT\u0026thinsp;=\u0026thinsp;Focal Psychodynamic Therapy \u003c/p\u003e \u003cp\u003eMANTRA\u0026thinsp;=\u0026thinsp;Maudsley Model of Anorexia Nervosa Treatment for Adults \u003c/p\u003e \u003cp\u003eFBT\u0026thinsp;=\u0026thinsp;Family Based Treatment\u003c/p\u003e \u003cp\u003eFT-AN\u0026thinsp;=\u0026thinsp;Family Therapy for Anorexia Nervosa\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe first-author (SC) employed an interpretive paradigm to RTA whereby they explored meanings, relations, nuances, contradictions and variations in people\u0026rsquo;s experiences whilst holding reflexive awareness of their own influence. Inductive and deductive approaches to coding and analysis were adopted; theoretical, research and experiential knowledge was drawn on to develop the research question and interview, however open coding was utilised to understand and emphasise participant meanings.\u003c/p\u003e \u003cp\u003eSC watched each recorded interview whilst reading the corresponding transcript, noting reflections. They then worked systematically through the dataset whereby data segments were given analytically-meaningful descriptions. Subsequently, code labels were collated and data segments for each code were compiled. Shared patterns of meaning were then identified whereby clusters of codes sharing a core concept were compiled as themes. Thereafter, themes were assessed as to whether they highlighted the most salient patterns of meaning and were reviewed for their core concept and fit into the data\u0026rsquo;s overall story. Lastly, the themes were named and given a synopsis whereby analytic narrative and data extracts were weaved together to address the research question.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eReflexivity\u003c/h2\u003e \u003cp\u003eThroughout the research, SC, the first author (I) reflected on my position as a white British heterosexual female trainee clinical psychologist with personal and professional experience of externalisation in treatments for AN. The process of keeping a reflexive journal and engaging in reflexive discussion in supervision helped to maintain clarity of thought about the topic and to hold an open, curious mind with an awareness of one\u0026rsquo;s own pre-conceived ideas. In line with the RTA approach, I utilised my subjectivity as a tool to delve deeper into the data and extrapolate meanings further.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe themes and subthemes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and subthemes developed during the analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeparation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIt was my voice, it was me\u003c/p\u003e \u003cp\u003eSeparation of Anorexia from myself\u003c/p\u003e \u003cp\u003eAre they my thoughts, or are they Anorexia\u0026rsquo;s?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaking sense of Anorexia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExternalising language\u003c/p\u003e \u003cp\u003eExternalising exercises\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA third entity in relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe therapeutic relationship\u003c/p\u003e \u003cp\u003eFamily and close others\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA relationship with Anorexia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA complex relationship\u003c/p\u003e \u003cp\u003eThe shift in relationship to Anorexia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManaging Anorexia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA constant presence; to listen, or not to listen?\u003c/p\u003e \u003cp\u003eAccountability and vulnerability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSeparation\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eIt was my voice, it was me\u003c/h2\u003e \u003cp\u003eParticipants reflected on initially experiencing no separation between themselves and AN. Consequently, they did not feel understood when others used externalising language; this incongruence negatively impacted on their trust in treatment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When it was first introduced, I didn't understand it, it affected the relationships because I felt like the people who were treating me didn't know what they were talking about, so I had no confidence in them\u0026rdquo; (P2).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIt was difficult to comprehend the notion of an external entity with its\u0026rsquo; own voice exerting influence over them. Hence, externalisation initially evoked \u0026ldquo;scepticism\u0026rdquo;, \u0026ldquo;confusion\u0026rdquo;, and increased resistance. However, later on in recovery, participants realised \u0026ldquo;two sides\u0026rdquo; within them; one that wanted the \u0026ldquo;comfort\u0026rdquo; and \u0026ldquo;safety\u0026rdquo; of AN, and one that wanted a \u0026ldquo;normal life\u0026rdquo;:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I really couldn't get my head around it as a young person, but I think as an adult it definitely became more useful and a bit more appropriate. I started to find it helpful in terms of maybe seeing the two separate sides of me\u0026rdquo; (P5).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participants emphasised that others should \u0026ldquo;wait until the person is ready\u0026rdquo; to be \u0026ldquo;receptive\u0026rdquo; to externalising their experiences. Some highlighted the therapeutic benefit of the therapist initially exploring what led to the person being in treatment, as well as efforts to build rapport \u0026ldquo;with the person\u0026rdquo;. These conversations led to their \u0026ldquo;own conclusions\u0026rdquo; about the problem\u0026rsquo;s influence on their lives.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSeparation of Anorexia from myself\u003c/h2\u003e \u003cp\u003eIn treatment, therapists would engage participants in conversations that differentiated between their \u0026ldquo;healthy self\u0026rdquo; and \u0026ldquo;the anorexia\u0026rdquo;:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We have discussions about whether I thought it was my healthy self or my eating disorder self that was making each decision\u0026rdquo; (P7).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e As treatment progressed, participants began to accept the notion that their thoughts, feelings and behaviours were under the influence of what felt like an \u0026ldquo;external force\u0026rdquo;. Engagement with this concept helped to promote engagement in treatment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I now refer to it as \u0026lsquo;the\u0026rsquo; eating disorder because it's not my problem\u0026hellip; a problem with my personality, it's not a part of me. It\u0026rsquo;s just an illness. And as it\u0026rsquo;s not a part of me, I feel I can treat it better; that helped me to recover\u0026rdquo; (P1).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe illness metaphor alleviated the perceived permanence of AN, deterring internalisation of the problem, which increased self-compassion, validation, and hope:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I needed to be reminded that I was a person beyond this. I'd forgotten\u0026hellip;I didn't have many memories of who I was before anorexia, so it was very helpful in reminding me that I wasn't just an illness\u0026rdquo; (P2).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe separation between self and AN enabled participants to \u0026ldquo;think more clearly\u0026rdquo; and access \u0026ldquo;a rational self\u0026rdquo;. They began to identify \u0026ldquo;anorexia thoughts\u0026rdquo; or \u0026ldquo;the anorexia voice\u0026rdquo; (both referred to hence forth as the AV) and separate these from thoughts perceived as generated by their \u0026ldquo;healthy self\u0026rdquo;:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It gave me a bit of direction because it gave me something specifically to challenge rather than it just being thoughts in my head\u0026rdquo; (P7).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis separation contributed to a perception of one\u0026rsquo;s difficulties as becoming \u0026ldquo;more practical\u0026rdquo;, \u0026ldquo;less emotional\u0026rdquo; and \u0026ldquo;more manageable\u0026rdquo;, enabling some participants to become more attuned to their needs:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Once you separate, it makes it easier to not do the things that it\u0026rsquo;s telling me to do, because I feel like I can say no to it if it\u0026rsquo;s not my thought\u0026hellip;like \u0026lsquo;I actually don't want to do that\u0026rsquo;\u0026rdquo; (P4).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eAre they my thoughts, or are they Anorexia\u0026rsquo;s?\u003c/h2\u003e \u003cp\u003eParticipants emphasised how difficult it was to distinguish what belongs to them and what belongs to the externalised ED. In reference to this dilemma, participants highlighted the influence of dominant discourses such as diet culture. Consequently, thoughts which appeared \u0026ldquo;normal\u0026rdquo; within their social-cultural context were described as \u0026ldquo;grey areas\u0026rdquo; evoking uncertainty as to whether one\u0026rsquo;s perceived \u0026ldquo;healthy self\u0026rdquo; thoughts were actually the AV \u0026ldquo;in disguise\u0026rdquo;:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026lsquo;Don't eat that because if you eat too much sugar, you\u0026rsquo;ll get diabetes\u0026rsquo;\u0026hellip;those kinds of thoughts were harder to externalise because they felt very normal\u0026rdquo; (P7).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen the AV and \u0026ldquo;healthy self\u0026rdquo; were not easily differentiated, participants became caught up in their thoughts and were less able to tune into their needs. Moreover, some questioned what the externalised entity was and how they should relate to it:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I didn't really know what it [the AV] was\u0026hellip;was it a separate being? or something in my brain that was telling me to do something?\u0026rdquo; (P6).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants continued to grapple with their conceptualisation of AN during recovery post treatment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Even now I still think \u0026lsquo;How can I want to do something that I don't want to do?\u0026rsquo; It\u0026rsquo;s a weird concept, even 10 years down the line\u0026rdquo; (P4).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eMaking sense of the Anorexia\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eExternalising language\u003c/h2\u003e \u003cp\u003e Participants reflected on the language used to make sense of their experiences in treatment. Some participants felt that combative language authorised a repositioning of themselves against the AV which they felt \u0026ldquo;neutral\u0026rdquo; language would not have. In this way, it felt \u0026ldquo;productive\u0026rdquo; to \u0026ldquo;fight against\u0026rdquo; the AV:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You could never really say anything neutral or that you're working with it in any way. It has to be \u0026lsquo;me against you\u0026rsquo; meaning, otherwise you're not recovering\u0026rdquo; (P4).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e However, other participants highlighted the importance of \u0026ldquo;neutral language\u0026rdquo; for combative language evoked exhaustion, a sense of failure, and a \u0026ldquo;louder\u0026rdquo;, \u0026ldquo;more controlling\u0026rdquo; AV. Instead, they found it helpful to adopt a diffusing stance in response to the AV:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It [combative language] made the eating disorder louder. A more compassionate voice towards the eating disorder was better for me. If I talked back to it, it became more of a conflicting argument and made the eating disorder want more control\u0026rdquo; (P6).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participants emphasised how therapists and treatment teams should be attuned to the emotional effects of externalising language and to how their experience of the same language could be helpful or hindering at different stages of recovery. For example, one participant initially found it more helpful to \u0026ldquo;question their own thoughts\u0026rdquo;, rather than consider the influence of an external entity. However, the way that they related to their eating behaviour changed later on in their recovery:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;At some point, it [externalisation] does make things slot together a bit. Rather than thinking \u0026lsquo;Oh, I\u0026rsquo;m crazy\u0026rsquo;, I now think \u0026lsquo;There was a force over me making me do that\u0026rsquo;. You start to think, \u0026lsquo;Oh, that makes a lot more sense\u0026rsquo;\u0026rdquo; (P4).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participants emphasised how crucial it is that therapists and treatment teams are led by the individual in order that externalising language has personal resonance. This approach was contrasted with the use of externalisation in a generalised, leading and assumptive manner. Hence, participants raised the importance of initially developing a shared understanding of the externalised concept:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think that if he'd [therapist] gone straight in with, \u0026lsquo;Oh think of it as a separate person to yourself\u0026rsquo;, I just wouldn't have got on with it because\u0026hellip;it would have felt weird to me. So it was a helpful process to discuss what that concept meant for me\u0026rdquo; (P7).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eExternalising exercises\u003c/h2\u003e \u003cp\u003eExternalising exercises, guided by the individual\u0026rsquo;s preferences, helped to create distance between the individual and AV. Letter writing was a difficult but \u0026ldquo;powerful\u0026rdquo; and validating task requiring \u0026ldquo;honesty\u0026rdquo;, \u0026ldquo;vulnerability\u0026rdquo; and \u0026ldquo;reflective\u0026rdquo; capacity. This process was helpful in supporting some participants to consider the functions and effects of the AV. However, others felt unable to engage in letter writing in a meaningful way because the exercise felt \u0026ldquo;trivial\u0026rdquo;, they did not have emotional or cognitive capacity, or they did not experience any separation between themselves and their internal dialogue around eating:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;As much as I can say that there's one side of me that\u0026rsquo;s that and there\u0026rsquo;s one side of me that\u0026rsquo;s the other, and there are different paths of thought, it very much still feels like it was a part of me\u0026rdquo; (P8).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Some participants felt that further abstracting the AV through visual imagery was not meaningful, whereas others felt that a visual representation gave them something \u0026ldquo;tangible\u0026rdquo; to communicate their experiences. However, it was essential that the image came from the individual rather than given to them. For instance, one participant was told to visualise an image of the AV which invalidated their distress:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026lsquo;Oh, just picture a goblin on your shoulders\u0026rsquo;, I feel like you don't understand. You have no idea how intense this is\u0026rdquo; (P5).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn contrast, being asked to draw their experience of the AV helped participants to express themselves in a way which enhanced therapists\u0026rsquo; perceived understanding:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I would imagine that the eating disorder thoughts were coming from that person [maleficent]. It helps me to separate it and to realise what was that voice and what was my own healthy voice. It helped her to see what I was imagining when I was thinking about the voice\u0026rdquo; (P9).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Letter writing to AN as a friend and enemy, and to ones\u0026rsquo; future self, as well as drawing AN were considered by some participants to be helpful at the time, however they did not feel the need to repeat these exercises. Instead, what helped to sustain recovery was continued daily management of their internal dialogue which they had practiced through role play, chair work or externalising conversations.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eA third entity in relationships\u003c/h2\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eThe therapeutic relationship\u003c/h2\u003e \u003cp\u003e Participants described ambivalence about treatment. Feeling \u0026lsquo;understood\u0026rdquo;, \u0026ldquo;seen as a person\u0026rdquo; and experiencing \u0026ldquo;connection\u0026rdquo; were significant in building trust in the therapist and treatment team, and in turn, in an externalised conceptualisation of their internal experiences:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I trust my therapist as a person. When I started to do it [externalisation], it was somebody that was consistent in my treatment. Being understood was definitely a big part of it. She seemed to understand exactly what was going on in my head and so because she understood it so well, it made me realise \u0026lsquo;Oh, I see, this is anorexia\u0026rsquo;\u0026rdquo; (P9).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Externalisation provided a \u0026ldquo;framework\u0026rdquo; and \u0026ldquo;common ground\u0026rdquo; to build a collaborative relationship, permitting the individual and therapist to stand together \u0026ldquo;on the same team\u0026rdquo; against the AV. Experiencing the therapist relate to them as a person beyond AN through the use of externalising language had a positive impact on participants\u0026rsquo; sense of self and instilled hope:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It [externalisation] allows me to see myself as a person and not the eating disorder. That made me feel that she [therapist] believed that I could get rid of it as well. Seeing that someone else sees that pushes you forward\u0026rdquo; (P12).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e However, some participants discussed that therapists should be careful not to \u0026ldquo;over externalise\u0026rdquo; their experiences as they perceived the AV to be external but also \u0026ldquo;a part of them\u0026rdquo;. Some participants described a demeaning experience within inpatient settings whereby externalising language was used in a way which contributed to them feeling overlooked and de-valued as a person:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Staff on the ward need to use it a lot less because the result is you feel belittled. It really annoyed me. If I didn't like a certain food, [\u0026hellip;] and the nurses would say \u0026lsquo;that's your eating disorder talking\u0026rsquo; (P13)\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurther, it was unhelpful for therapists and treatment teams to take an \u0026ldquo;aggressive\u0026rdquo;, \u0026ldquo;controlling\u0026rdquo; or \u0026ldquo;forceful\u0026rdquo; stance during externalising conversations as they evoked heightened emotions and caused participants to retreat into the ED:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When people try and enforce things on me, things get a lot harder for them because I dig my heels in, and this is probably where I switch into anorexia mode\u0026rdquo; (P11).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e It was more helpful for the therapist to use externalisation in a \u0026ldquo;subtle\u0026rdquo;, sensitive manner through engaging participants in conversations which explored the influence of AN on their lives, whilst acknowledging who they are as a person and the complexity of their relationship with the AV. In the context of a positive therapeutic relationship, participants began to replace trust in the AV with trust in their therapist:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I started to hear my therapists\u0026rsquo; voice there as well saying what I should\u0026hellip;what is the healthy response? I think as I started to trust her more, I started to listen to the anorexia voice less\u0026rdquo; (P9).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eFamily and close others\u003c/h2\u003e \u003cp\u003eMost participants conveyed how others\u0026rsquo; use of externalising language early on in their recovery could cause conflict, disconnection and distance in their relationships because they felt misunderstood and frustrated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When I was still very unwell, it made me feel very alone and isolated because no one was understanding me and what was going on for me in my head. It used to really make me cross when my mum would say, \u0026lsquo;That's anorexia talking\u0026rsquo; because I didn't know that that was the anorexia talking\u0026rdquo; (P2).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e However later on, some participants felt that the conceptualisation of AN as an external illness or entity helped them to explain their experiences to family and close others in a way that increased their empathic understanding. However, significant to feeling understood was that family and close others used the same language as participants and that they were sensitive to the functions of the externalised AN. One participant related their family\u0026rsquo;s difficulty engaging in family therapy to their family\u0026rsquo;s understanding of AN:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They very much saw it as \u0026lsquo;(participant\u0026rsquo;s name\u0026rsquo; is the one that\u0026rsquo;s ill or she\u0026rsquo;s got this person on her shoulder\u0026rsquo; but in that sense, it didn't help them to be more open to seeing it as a systemic issue\u0026rdquo; (P13).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e It was important that family and close others understood the influence of AN on participants\u0026rsquo; thoughts, feelings and behaviours. Some participants felt that family and close others struggled to grasp an externalised conceptualisation of their difficulties and that this impacted on their containment of emotion and led to relational ruptures. Other participants explained how viewing the AV as an external force helped to alleviate relational strain through supporting family and close others to manage difficult emotions, and reducing their own shame and guilt related to the impact of their difficulties on others:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It makes it easier for family and friends to understand that it's not you that's behaving in that way, you're not choosing to behave in the way that you are. Cause that's what a lot of people think about eating disorders - that it's a choice to do what you do\u0026rdquo; (P3).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, it was unhelpful when family and close others attributed all of their communication to \u0026ldquo;the eating disorder\u0026rdquo;, or when they used language which evoked feelings of failure and distress. One participant explained how their friends\u0026rsquo; use of adversarial metaphors contributed to their withdrawal from the relationship and their retreat into the ED:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When I'm hearing it from my therapist, it's calm and reassuring. But with my friends, it's forceful\u0026hellip;it's completely different, and that puts me more on edge. It makes me feel more of a failure if things don't go right\u0026rdquo; (P11).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eA relationship with Anorexia\u003c/h2\u003e \u003cdiv id=\"Sec28\" class=\"Section4\"\u003e \u003ch2\u003eA complex relationship\u003c/h2\u003e \u003cp\u003eMost participants explained that externalisation \u0026ldquo;was not the solution\u0026rdquo; as they continued to feel controlled by the AV. Some participants felt confronted and overwhelmed by their relationship to the AV when their experiences were externalised:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I despised it [AN]. When it wasn\u0026rsquo;t a part of me, I still to some extent, felt like it was a part of my life, and then obviously it meant there was another\u0026hellip;problem\u0026hellip;to deal with\u0026rdquo; (P1).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants described how externalisation contributed to them feeling that \u0026ldquo;control\u0026rdquo; or \u0026ldquo;a piece of them\u0026rdquo; was being taken away. In recovery, participants reflected on missing the \u0026ldquo;protective\u0026rdquo; functions of their relationship with the AV during times of difficult emotion. Therefore, emphasis was placed on \u0026ldquo;not trusting\u0026rdquo; the AV. Some participants questioned whether externalisation contributed to their attachment to the AV. One participant at an earlier stage of recovery described fear and anticipatory loss in their relationship to the externalised AN:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;By externalising it, am I going to go through the grief period of loss because it's been a part of me for so long, and now that we are separating it and I'm moving away from it, well that\u0026rsquo;s the idea. Is that then going to kick off another relapse? Am I gonna be lost without it and want it back?\u0026rdquo; (P11).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe importance of exploring and understanding the development and function of the individual\u0026rsquo;s relationship with the AV was emphasised. This served to reduce AN\u0026rsquo;s \u0026ldquo;bargaining power\u0026rdquo;, increase compassionate self-understanding and self-confidence in relation to the AV:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Rather than me deciding to have it in my life, I\u0026rsquo;ve looked at it as a separate being that's tried to intervene and interrupt things. Therapy allowed me to become more self-aware, but also understand why the eating disorder\u0026rsquo;s there in the first place\u0026rdquo; (P6).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eThe shift in relationship to Anorexia\u003c/h2\u003e \u003cp\u003eExternalisation helped to increase hope through creating space for participants to consider \u0026ldquo;what they truly wanted\u0026rdquo; in life. The separation made it easier to visualise the \u0026ldquo;freedoms\u0026rdquo; that may be experienced without the AV\u0026rsquo;s influence. However, losing this relationship felt \u0026ldquo;daunting\u0026rdquo; because participants did not know who they were without it. Consequently, externalising conversations which were focussed on \u0026ldquo;strengthening\u0026rdquo; one\u0026rsquo;s \u0026ldquo;healthy self\u0026rdquo; were more empowering than solely focusing on eradicating AN. Accordingly, externalising conversations which facilitated reflection on personal values and aspirations helped participants to become more in touch with themselves, which in turn harnessed strength and determination to resist the AV:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Exploring my values as a person was really helpful in strengthening my own identity and helping me to externalise the anorexia voice because anorexic values are not my values, so why am I listening to it\u0026rdquo; (P11).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participants accentuated the significance of experiencing a sense of \u0026ldquo;worth\u0026rdquo; and \u0026ldquo;purpose\u0026rdquo; in their lives in order to feel willing to detach themselves from the AV. What helped participants to stay well was reminding themselves of the impact that AN had on their lives, and their prioritisation of important relationships and aspects of life over their relationship with the AV:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I know it can ruin marriages, friendships\u0026hellip;it's really powerful. Thinking of it as a separate thing, I can think \u0026lsquo;Well, you're not gonna ruin my marriage\u0026rsquo;, \u0026lsquo;You're not gonna ruin my career\u0026rsquo;\u0026rdquo; (P4).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eManaging Anorexia\u003c/h3\u003e\n\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eA constant presence; to listen, or not to listen?\u003c/h2\u003e \u003cp\u003eParticipants continued to feel in relationship with the AV post-treatment and weight-restoration. However, maintaining a sense of distance between self and the AV enabled participants to minimise its influence:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Being able to separate the two voices is one of the things that has helped me to stay well because I can say, \u0026lsquo;Okay, I'm not listening to... that\u0026rsquo;s the eating disorder voice\u0026rsquo;\u0026rdquo; (P8).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHence, externalisation enabled participants to live \u0026ldquo;a normal life\u0026rdquo; alongside the AV:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It's been an ongoing cycle that I've been in all my life. So, it's about managing my illness, allowing me to still do the things that I have to do\u0026rdquo; (P11).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants acknowledged how easily they could \u0026ldquo;slip back\u0026rdquo; \u0026ldquo;under the spell\u0026rdquo; of the AV. Understanding when and how it tried to intervene during times of vulnerability was crucial in staying well:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I know that I've got something that people don't have that has the potential to destroy me and my sanity, or I can try to be stronger than it and do what I can to work against it\u0026rdquo; (P4).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants attributed belief that they \u0026ldquo;would never fully recover\u0026rdquo; to their \u0026ldquo;personality\u0026rdquo;, \u0026ldquo;genetics\u0026rdquo; and/or \u0026ldquo;brain structure\u0026rdquo;. However, externalisation fostered a sense of \u0026ldquo;choice\u0026rdquo; over whether they allow AN to be a part of their life:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If it's part of you, as long as you exist, it's going to exist as well. But thinking of it as something that\u0026rsquo;s separate makes me feel like it doesn't have to be there all the time. I feel I can carry on life without it\u0026rdquo; (P3).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRelapse was conceptualised as \u0026ldquo;listening to the voice again\u0026rdquo;; choosing not to listen to the AV was crucial in reducing this risk:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It's almost like another voice that I'm trying to just leave behind or ignore. And the more you ignore it, the better you get at it\u0026rdquo; (P4).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eAccountability and vulnerability\u003c/h2\u003e \u003cp\u003eParticipants expressed difficulty taking accountability through a tendency to blame their actions on a \u0026ldquo;third person\u0026rdquo;. Some participants conveyed how externalisation could give, but also take their \u0026ldquo;power\u0026rdquo; because the external entity became an \u0026ldquo;oppressive\u0026rdquo;, \u0026ldquo;omniscient figure\u0026rdquo; that was \u0026ldquo;impossible to stand against\u0026rdquo;. These participants considered whether it would be helpful to use language which evoked less fear:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;tread carefully not to overdo it so it becomes an invincible, powerful thing that becomes an excuse\u0026hellip;you're like, well, I don't have control because it's actually not me that\u0026hellip;the eating disorder is telling me this so therefore, I'm not going to eat\u0026rdquo; (P13).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne participant discussed how her husband did not use externalising language and spoke to her directly about \u0026ldquo;making the right decisions\u0026rdquo;. Being spoken to as though she had authority over her eating behaviour empowered her to sustain recovery:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;You don\u0026rsquo;t have to be accountable for your actions when you have a\u0026hellip;when it\u0026rsquo;s something you want to do in secret and you've got someone to blame, it goes hand in hand. Him holding me accountable for my own actions stops either of us blaming it on a third party\u0026rdquo; (P4).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participants experienced shame, guilt and fear of disappointing their therapist when they had \u0026ldquo;given in to the voice\u0026rdquo;. However, externalisation helped to mitigate difficult feelings in the therapeutic relationship as they could \u0026ldquo;blame\u0026rdquo; their actions on \u0026ldquo;the eating disorder\u0026rdquo;. Sharing one\u0026rsquo;s internal experiences with others could feel exposing and unsafe, however talking about the influence of an external entity provided a way of communicating which required less vulnerability, making interactions with their therapist feel less intense, attacking and threatening. Some conveyed how talking about a \u0026ldquo;practical\u0026rdquo; \u0026ldquo;manifestation\u0026rdquo; helped to keep distance in the therapeutic relationship:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s kind of \u0026lsquo;It's happening over there\u0026rsquo;\u0026hellip;So it's more about keeping someone else at arm's length\u0026rdquo; (P5).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eParticipants described a journey in terms of their experience of externalisation in recovery from AN. This journey is depicted through each main theme which is discussed in relation to theory, research and clinical implications.\u003c/p\u003e \u003cp\u003e Making sense of the externalised AN entity was an ambiguous process; participants questioned whether the AV was \u0026ldquo;a separate being\u0026rdquo;, \u0026ldquo;a part of themselves\u0026rdquo;, or \u0026ldquo;something in their brain\u0026rdquo;. This finding is consistent with research which demonstrates that AN is difficult for individuals to make sense of, with some individuals holding dual concepts of AN as both a part of themselves and as separate from their identity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The findings provide further insight by illustrating how an externalised conceptualisation of ones\u0026rsquo; internal dialogue can be initially difficult to comprehend. However, through the use of externalising language throughout treatment, participants began to engage with the notion of an internal \u0026ldquo;anorexia voice\u0026rdquo; which was to some extent split from the self. Over time and in the context of positive therapeutic relationships, engagement with this concept aided engagement in treatment, suggesting that externalisation is an important component of treatment for AN.\u003c/p\u003e \u003cp\u003eNevertheless, the findings provide insight into the complexity of the self in relation to the AV. Dialogical Self Theory is based on theories of self-multiplicity and assumes that the mind contains multiple \u0026lsquo;I- positions\u0026rsquo; which can agree or oppose one another [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].The internal dialogue between the different positions is important for the development and maintenance of personal identity [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The multi-voiced self can become dysfunctional if the person has a limited number of self-positions, they are not aware of other positions, or they are aware of competing positions but are not able to reach an overarching point of view to reveal a new position [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. From this perspective, the externalised AN (the AV) is one I-position and ED recovery is thought to be related to changes in the dialogical self, such as the strengthening of adaptive internal voices to counteract the AV [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].The findings illustrate how externalisation can help individuals to obtain distance from the AV, as well as access and strengthen an alternative I-position through separating the AV from a \u0026lsquo;healthy self\u0026rsquo; which is nurtured to reduce the AVs influence.\u003c/p\u003e \u003cp\u003eThe findings are consistent with research demonstrating that at the onset of AN, individuals experience the I-position taken up by AN as positive and functional, however, as the ED progresses, individuals perceive the AV to be a controlling, critical, dominant and bullying external force [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The findings demonstrate how externalisation can support this shift in perspective by facilitating the individual\u0026rsquo;s reflection on the effects of the AV on their lives. Nonetheless, dominant diet-related discourses made it difficult for participants to differentiate between the healthy self and AV within their internal dialogue. Hence, supporting individuals to navigate the impact of dominant diet-related discourses when externalising AN may positively impact on people\u0026rsquo;s recovery.\u003c/p\u003e \u003cp\u003eThe findings underscore the importance of being individual-led when making sense of the AV. The intended effects of externalisation are diminished in the absence of a context in which the client is viewed as the expert on their life [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Hence, curiosity and willingness to ask questions to which the therapist does not know the answer are essential narrative therapy principles that underpin personally meaningful externalising conversations [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. It was hindering to participant\u0026rsquo;s engagement when therapists and treatment teams enforced their own conceptualisations of AN onto the individual\u0026rsquo;s experiences. Hence, the findings accentuate the importance of using language that is congruent with the individual\u0026rsquo;s lived experience. This aligns with research which suggests that verbal synchrony between patients and their therapists contributes to positive treatment outcomes for AN [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRelatedly, the findings stress the importance of paying attention to individuality, for each participants\u0026rsquo; experience of externalising practices was unique, and the same practice could be helpful or hindering at different stages of recovery. White asserts that therapists should continually consult with people about the perceived effects of their therapeutic work to ensure it remains meaningful, relevant and helpful [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Thus, regularly reviewing the effects of externalising practices with individuals in treatment may help to promote their positive effects.\u003c/p\u003e \u003cp\u003e Participants appreciated the therapist taking up a compassionate, non-coercive and neutral stance during externalising conversations. Within the context of a previous high level of intervention for a persistent problem, rather than directly attempting to vanquish problems from people\u0026rsquo;s lives, it can be conducive to start with creating a reflective space through externalising conversations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Participants valued externalising practices which acknowledged their attachment to AN over a \u0026lsquo;forceful\u0026rsquo; approach in which the therapeutic focus was eradicating AN. This may be related to the bond between the individual and AV which is thought to explain ambivalence to change [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The latter studies advocate that therapists penetrate the tie between the individual and AV, whilst acknowledging the AV\u0026rsquo;s hold. White emphasises that early externalising conversations should not focus on encouraging the individual to engage in a struggle with the problem, but rather to develop a shared understanding of the problem\u0026rsquo;s character, operations, activities, and purpose [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. White termed this \u0026lsquo;cool engagement\u0026rsquo; and discussed how this posture can alleviate vulnerability and distress in relation to the voice of a problem, in comparison to a \u0026lsquo;hot engagement\u0026rsquo; which promotes direct confrontation with it. Therefore, in contrast to taking a directive, confrontational approach to the AV, it may be beneficial for therapists to create a reflective space for the individual to explore, understand and revise their relationship with the AV.\u003c/p\u003e \u003cp\u003e Participants expressed particular familiarity with combative language in treatments for AN. Metaphors are significant in externalising conversations; they are borrowed from discourses that contribute to specific understandings of life and identity and therefore shape an individual\u0026rsquo;s life and opportunities for action in relation to a problem [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Adversarial metaphors such as \u0026lsquo;fighting\u0026rsquo; can contribute to feelings of defeat, failure, fatigue, overwhelm and reduced personal agency [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Furthermore, totalising the problem (dualistically defining it in totally negative terms) can obscure its broader context and invalidate what people give value to [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Hence, White did not intend for the position taken in relation to the problem to be either for, or against. Instead, the individual is invited to take a position that creates space for them to begin to reclaim their life from its effects. White suggests that to support individuals to revise their relationship to a problem, therapists should prioritise the use of metaphors which do not have adverse effects [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Accordingly, reclamation metaphors (e.g., \u0026lsquo;getting one\u0026rsquo;s life back from the problem\u0026rsquo;) should be prioritised over competition metaphors (e.g., \u0026lsquo;beating the problem\u0026rsquo;). Externalising the AV by commanding and gaining control over it is considered an important aspect of recovery [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] Jenkins \u0026amp; Ogden, 2012). Thus, it is common that metaphors privileged in treatment place people in a \u0026lsquo;battle\u0026rsquo; or \u0026lsquo;fight\u0026rsquo; \u0026lsquo;against AN\u0026rsquo;. However, \u0026lsquo;fighting\u0026rsquo; the AV has been associated with more severe ED symptoms and distress [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Therefore, researchers have begun to question which ways of responding to the AV are helpful versus problematic, suggesting that \u0026lsquo;compassionate assertiveness\u0026rsquo; may be a helpful response [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Combative language increased motivation to resist the AV for some, whereas for others, it activated their threat response, increasing the AVs dominance and the individuals\u0026rsquo; submission. For these individuals, compassionate assertiveness and distancing from rather than arguing with the AV was more helpful. The findings are consistent with research in psychosis which suggests that aggressive counter-responding can stimulate threat-focused affective systems and heighten attention towards voices [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Difficulty tolerating negative emotion is a trigger for engaging with the AV [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Therefore, Kater discusses the therapeutic benefit of using Acceptance and Commitment Therapy (ACT), stating that using hard data to argue with ED thoughts is not helpful in managing obsessive thoughts and preoccupation [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. The findings support the aforementioned studies and suggest that individuals who experience increased preoccupation and distress on attempting to \u0026ldquo;fight\u0026rdquo; the AV may find it more helpful to adopt a defusing stance.\u003c/p\u003e \u003cp\u003eThe findings indicate that externalising practices are most helpful when they allow an individual to feel \u0026ldquo;seen as a person\u0026rdquo;. Clients consider the care relationship to be a meaningful contributor to recovery [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]; feeling treated as a \u0026lsquo;whole person\u0026rsquo; and having a \u0026lsquo;real relationship\u0026rsquo; with the therapist are regarded as significant [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. The findings demonstrate how helpful externalising practices can positively impact on an individual\u0026rsquo;s self-concept through enabling them to feel realised by their therapist. This finding is consistent with research which concluded that the individual\u0026rsquo;s visual of themselves is expanded through them feeling treated as a person who is more than AN by their therapist [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings support research which suggests that externalising the AV can provide a common language for therapist and client to work collaboratively despite the experience of ambivalence [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. They also provide further insight by demonstrating that individuals need to develop trust in their therapist to become open to an externalised conceptualisation of their internal experiences. Individuals with AN deem a sense of connectedness between themselves and their therapist to be important for them to engage in adaptive relational processes, for instance self-disclosure [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Developing a shared understanding of the AV enabled participants to experience connection with their therapist, which in turn aided self-disclosure through mitigating the experience of shame. In the context of a trusting therapeutic relationship, individuals internalised their therapists\u0026rsquo; voice and drew on it to respond to the AV. In narrative therapy, the therapists\u0026rsquo; position taken in relation to their client, and the relationship between them are considered fundamental in bringing about positive change [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Therefore, externalisation is thought to be therapeutically powerful because it reflects the quality of a relationship, rather than a technique [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The findings illustrate how externalisation can aid the development of a positive therapeutic relationship in which the individual feels supported to revise their relationship with the AV within the containment of this alliance.\u003c/p\u003e \u003cp\u003eExternalisation of AN as an external illness or entity helped to mitigate against family and close other\u0026rsquo;s perception that EDs are a \u0026ldquo;choice\u0026rdquo;, which in turn supported participants to maintain their important relationships. The findings are consistent with research demonstrating that caregivers can find it helpful to perceive AN as a separate entity as it enables them to attribute negative feelings to the ED rather than the individual [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. However, they also provide new insight by demonstrating that when family and close others use language which is not congruent with the individuals\u0026rsquo; understanding of their experience, or when it has adverse emotional effects, externalisation can negatively impact on relationships and recovery. White and Epston emphasised that the externalised problem definition should be mutually acceptable [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, the FBT manual suggests picking a metaphor that works best for parents [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The findings suggest it is crucial that family and close others use the individual\u0026rsquo;s own experience-near language. Further, that they should be careful not to over-externalise the individual\u0026rsquo;s experiences as this may contribute to relational ruptures.\u003c/p\u003e \u003cp\u003eThe findings elucidate the risk that conceptualising AN as an external illness or third-entity might detract from psychological formulation which may contribute to family member understanding that the problem resides within the individual. Positive, helpful experiences of personal relationships are significant in AN recovery [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. White advocated that the development of a shared understanding of the externalised problem within the context of the individual\u0026rsquo;s life experiences can assist their support network to be more containing and supportive of their needs and difficulties [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Participants reflected on the function of their relationship to the AV in terms of helping them to manage emotions that arose from life stressors, transitions, interpersonal relationships and sociocultural pressures. Hence, it is important that others\u0026rsquo; conceptualisations of AN acknowledge the psychological, emotional and social-cultural factors which contribute to its development and maintenance.\u003c/p\u003e \u003cp\u003eWhilst individuals feared the externalised AN and felt controlled by it, they also felt attached to it, daunted by the loss of it and missed it in recovery. Individuals describe their ED as \u0026lsquo;a life jacket\u0026rsquo; that provides control, isolation, security, identity, and a tool for emotion regulation and avoidance [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Emphasising the negatives of AN without exploring its functions fails to acknowledge the meaning of ED behaviours, invalidates the individual, and neglects opportunity for finding alternative mechanisms through which needs can be met [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Exploring and understanding ones\u0026rsquo; relationship with the AV through the use of externalising conversations and exercises which encouraged reflection on the AV\u0026rsquo;s function and effects enabled some participants to process their thoughts, feelings and experiences in relation to the AV and subsequently attempt to meet its perceived functions through alternative means. Therefore, externalising conversations which aid the development of self-understanding may help to reduce enmeshment with the AV. In contrast, using externalising language to emphasise attempts to vanquish AN without acknowledging its role within the individual\u0026rsquo;s life may serve to increase resistance.\u003c/p\u003e \u003cp\u003eThe findings are consistent with research which conceptualises EDs as attachment-relationships [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. Research has questioned whether the individual-AV relationship is reflective of early attachments and interpersonal ways of relating [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. It has been suggested that exploring the individual-AV relationship may help to resolve relational patterns and attachment-related issues which maintain AN [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The findings demonstrate how externalisation can aid this process by facilitating the development of a relational understanding of AN. For instance, letter writing and chair work opened space for participants to speak to the AN entity that they experienced themselves as being in relationship with. However, given the attachment themes and interpersonal patterns within participants\u0026rsquo; narratives in relation to the AV and therapeutic relationship, it may be beneficial to utilise externalisation to explore the individual-AV relationship in the context of attachment-related issues and the clients\u0026rsquo; interpersonal patterns. Emerging research demonstrates that the importance of using therapeutic approaches that address relational trauma with individuals who experience an AV [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Exploring the influence of early relationships and childhood experiences on the development of the AV may help to provide individuals with a greater sense of understanding in relation to their experience of AN.\u003c/p\u003e \u003cp\u003eThe narratives depict an interwoven relationship between vulnerability and accountability in relation to externalisation. They are consistent with research which depicts the experience of AN as being entrapped in a toxic, enmeshed relationship in which the self is shared with AN [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. Internal ED dialogue reflecting an \u0026lsquo;abusive relationship\u0026rsquo; predicts ED severity, suggesting that in order to enhance personal agency, the connection between negative appraisals of the \u0026lsquo;abused self\u0026rsquo; and the abusive voice of the ED must be alleviated [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. Some participants questioned whether externalising AN as a powerful third-entity gave the AV more authority and reduced their sense of agency. Referral to the ED as a separate entity, as though it has a life of its own is a common discursive phenomenon between healthcare professionals and service-users [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. A \u0026lsquo;stronger AV\u0026rsquo; (i.e., with higher levels of voice power, omnipotence, entrapment and defeated response) is associated with increased ED severity and duration [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Therefore, certain appraisals of the AV may hinder recovery by further exacerbating identification with an abused self, increasing distress and feelings of entrapment. Individuals with lived experience of AN regard empowerment consisting of taking responsibility and control leading to confidence, agency, resilience, autonomy and independence to be significant in recovery [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Therefore, therapists and treatment teams should be cautious of using language which empowers rather than disempowers individuals in relation to their experience of eating difficulties.\u003c/p\u003e \u003cp\u003eExternalising practices which gave voice to participants\u0026rsquo; values, purpose, commitments and aspirations versus those of the AV\u0026rsquo;s were significant in helping individuals to realise their life unlived due to AN. White\u0026rsquo;s rationale for externalising conversations was to make it possible for people to experience an identity that is separate from the problem; to open possibilities for the pursual of what is personally important [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In the course of AN, it can become increasingly difficult for people to find an alternative identity [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Individuals often comprehend recovery as desirable yet \u0026lsquo;unattainable\u0026rsquo; and \u0026lsquo;unimaginable\u0026rsquo; [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e] as they fear losing a major part of their identity [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Hence, imparting hope can enhance therapeutic alliance and in turn improve outcomes [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. The findings depict how externalising practices can increase hope by helping individuals to connect with a seemingly \u0026lsquo;unimaginable future self\u0026rsquo; through not only feeling realised by others, but also by their selves. Hence, reflective practices that open space for an alternative narrative identity to develop and be thickened may increase people\u0026rsquo;s willingness to \u0026ldquo;let go\u0026rdquo; of AN.\u003c/p\u003e \u003cp\u003e Lastly, distancing one\u0026rsquo;s self from the AV was a practice that participants used to minimise the AV\u0026rsquo;s influence on their life post-treatment and weight-restoration. Individuals who have been discharged from treatment after reaching a healthy weight describe AN recovery as an on-going process and emphasise the importance of psychological change (e.g., motivation and belief in the capacity to change) in sustaining recovery and managing relapse risk [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]. The findings suggest that externalisation can aid these processes of psychological change. For instance, externalisation provided participants with a sense of agency over how much influence they allowed the AV to have on their lives.\u003c/p\u003e \u003cdiv id=\"Sec34\" class=\"Section2\"\u003e \u003ch2\u003eReflexivity\u003c/h2\u003e \u003cp\u003eI (the first author) approached this research with awareness of how my experiences which had shaped my views on the role of externalisation would influence my approach to this research. Prior to this study, I had observed how some individuals experienced vulnerability in relation to the entity that was externalised in treatment. In turn, I became curious as to whether the creation of an external entity through the use of language could increase fear and passivity in relation to one\u0026rsquo;s internal dialogue (the AV). Consequently, I approached data collection and analysis with interest in the emotional and relational effects of externalising practices. Accordingly, during the write-up of this research, focus was placed on the role of language in serving to empower versus disempower individuals in relation to eating difficulties.\u003c/p\u003e \u003cp\u003e Within my reflexive journal, I acknowledged that I would need to be attuned to the language used by individual participants to describe their experiences. Adopting their choice of language enabled me to avoid imposing my own assumptions and to obtain an accurate understanding of participants\u0026rsquo; views. I also noted that I may display particular interest in issues which personally resonated. To limit the impact of this, I was conscious of my role as a researcher and endeavoured to display equal interest in issues which did and did not have personal resonance.\u003c/p\u003e \u003cp\u003eWhilst the negative impact of viewing AN as an external entity was present within my interpretation of the data (e.g., through reducing personal agency and accountability), I also recognised contradictions to this where some participants described how this conceptualisation had a positive impact on recovery (e.g., through alleviating the perceived permanence of the problem and enhancing motivation). I realised that peoples\u0026rsquo; experiences of externalisation were varied and nuanced; further, that this would need to be reflected within the write up.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStrengths, limitations and further research\u003c/h3\u003e\n\u003cp\u003eHolding \u0026lsquo;insider research\u0026rsquo; status has both advantages and disadvantages [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. An advantage relevant to this study was the potential for a greater level of trust between participants and researcher [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. This was observable throughout the interview process whereby the first author perceived a strong connection with participants. Consequently, the interviews were long in duration due to the rich and in-depth conversations about participants\u0026rsquo; experiences, resulting in high-quality data.\u003c/p\u003e \u003cp\u003eHowever, the role of the insider-researcher in shaping knowledge production must be acknowledged rather than assuming that it offers a \u0026lsquo;correct\u0026rsquo; way of viewing the population under study [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. The involvement of service-users in the development of the interview schedule may have mitigated against the latter by eliciting a wider range of interview questions and findings. Nonetheless, in line with an RTA approach, the first-author actively followed up what they interpreted as being meaningful to participants [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. Additionally, the final interview question asked participants if there was anything that had not been asked which they felt was important to share. It is hoped that this question permitted participants the opportunity to share experiences and views which were not guided by the researchers. Nevertheless, the experiential knowledge of living with a condition provides relevance and credibility to research [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. Hence, future research focussed on externalisation would benefit from involving service-users in the development of the interview schedule.\u003c/p\u003e \u003cp\u003eMoreover, the sample was largely homogeneous and individuals who identify as male, or non-binary, as well as individuals from ethnic backgrounds other than white-British are underrepresented, thus replicating issues within the ED research field [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. Both gender and ethnicity influence the experience of AN [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e, \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e]. Hence, eliciting insight into people\u0026rsquo;s experiences of externalisation in a more diverse sample may contribute to greater variation in the experience of externalisation.\u003c/p\u003e \u003cp\u003eAdditionally, all participants were aged 20 and above and identified as being \u0026lsquo;in recovery\u0026rsquo;. Thus, future research should explore the experience of externalisation in treatment for AN among children, young people and families. Lastly, exploring experiences of externalisation among individuals who identify as \u0026lsquo;fully recovered\u0026rsquo; or \u0026lsquo;not recovered\u0026rsquo; may shed light on how externalisation supports full remission from AN.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eExternalisation is a popular intervention in treatments for AN. The findings underscore the importance of using externalisation in a person-centred manner, underpinned by narrative therapy principles, to ensure that language empowers rather than disempowers individuals. Accordingly, the findings highlight the importance of working with individuals to develop a psychologically informed understanding of their experiences of AN, as well as to strengthen an alternative narrative identity in line with their personal values. These findings may serve to prompt clinicians, treatment teams, and family members to be attuned to the individual\u0026rsquo;s emotions and experience of externalising language so they can support individuals with AN as helpfully as possible.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUK: United Kingdom\u003cbr\u003e\u0026nbsp;AN: Anorexia nervosa\u003cbr\u003e\u0026nbsp;ED: Eating disorder\u003cbr\u003e\u0026nbsp;AV: Anorexia voice/ thoughts\u003cbr\u003e\u0026nbsp;FBT: Family based treatment for Anorexia nervosa\u003cbr\u003e\u0026nbsp;FT-AN: Family therapy for Anorexia nervosa\u003cbr\u003e\u0026nbsp;Author 1: SC\u003cbr\u003e\u0026nbsp;Author 2: MP\u003cbr\u003e\u0026nbsp;Author 3: LS\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the participants who gave their time and emotional energy to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSC lead on data collection, analysis, and writing this paper. MP and LS conceptualised and supervised the study, and edited the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the University College of London.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are confidential due to the need to protect the privacy of participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the University College of London Research Ethics Committee (Approval number: 22063/001). Participants provided consent to participate via a pre-interview questionnaire administered online.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data has been anonymised and all participants provided written and verbal consent for the inclusion of their anonymised data to be included within this report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch Department of Clinical, Educational and Health Psychology, University College of London, Gower Street, London WC1E 6BT, UK.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe online version contains supplementary material available at\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKhalsa SS, Portnoff LC, McCurdy-McKinnon D, Feusner JD. What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa. Journal of Eating Disorders. 2017;5(1):1-12. https://doi.org/10.1186/s40337-017-0145-3\u003c/li\u003e\n\u003cli\u003eEddy KT, Tabri N, Thomas JJ, Murray HB, Keshaviah A, Hastings E, et al. Recovery from anorexia nervosa and bulimia nervosa at 22-Year Follow-Up. The Journal of Clinical Psychiatry. 2016;78(02):184\u0026ndash;9. https://doi.org/10.4088/jcp.15m10393\u003c/li\u003e\n\u003cli\u003eMurray SB, Quintana DS, Loeb KL, Griffiths S, Le Grange D. Treatment outcomes for anorexia nervosa: a systematic review and meta-analysis of randomized controlled trials. Psychological Medicine. Cambridge University Press; 2019;49(4):535\u0026ndash;44. https://doi.org/10.1017/S0033291718002088 \u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence. Eating disorders: recognition and treatment. NICE guideline [NG69]. 2017. https://www.nice.org.uk/guidance/ng69/chapter/Recommendations#treating-anorexia-nervosa. Accessed 11 Oct 2023.\u003c/li\u003e\n\u003cli\u003eLock J, Le Grange D. Treatment manual for anorexia nervosa: A family-based approach. New York: Guilford publications; 2015.\u003c/li\u003e\n\u003cli\u003eSimic, M., Eisler, I. Maudsley Family Therapy for Eating Disorders. In: Lebow J, Chambers, A, Breunlin D, editors. Encyclopedia of Couple and Family Therapy. Springer, Cham; 2018. p. 1-9. https://doi.org/10.1007/978-3-319-15877-8_168-1\u003c/li\u003e\n\u003cli\u003eLock A, Epston D, Maisel R. Countering that which is called anorexia. Narrative Inquiry. 2004;14(2):275\u0026ndash;301. https://doi.org/10.1075/ni.14.2.06loc\u003c/li\u003e\n\u003cli\u003eChimp\u0026eacute;n-L\u0026oacute;pez C, Mu\u0026ntilde;oz RA. Narrative therapy for anorexia nervosa: using documents of resistance. Australian and New Zealand Journal of Family Therapy. 2021;42(3):276\u0026ndash;91. https://doi.org/10.1002/anzf.1459\u003c/li\u003e\n\u003cli\u003eRienecke RD, Grange DL. The five tenets of family-based treatment for adolescent eating disorders. Journal of Eating Disorders. 2022;10(1):1-0. https://doi.org/10.1186/s40337-022-00585-y\u003c/li\u003e\n\u003cli\u003eWaller G, Cordery H, Corstorphine E, Hinrichsen H, Lawson R, Mountford V, et al. Cognitive behavioral therapy for eating disorders: A comprehensive treatment guide. Cambridge: Cambridge University Press; 2007. https://doi.org/10.1017/cbo9781139644204\u003c/li\u003e\n\u003cli\u003eLock J. Adolescent-focused therapy for anorexia nervosa: a developmental approach. New York: Guilford Publications; 2020.\u003c/li\u003e\n\u003cli\u003eFitzpatrick K, Moye A, Rienecke RD, Lock J, Grange DL. Adolescent focused psychotherapy for adolescents with anorexia nervosa. 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Faculty Publications \u0026ndash; Graduate School of Counseling. 2008; 15. https://digitalcommons.georgefox.edu/gsc/15?utm_source=digitalcommons.georgefox.edu%2Fgsc%2F15\u0026amp;utm_medium=PDF\u0026amp;utm_campaign=PDFCoverPages\u003c/li\u003e\n\u003cli\u003eMorgan, A. What is narrative therapy?: An easy-to-read introduction. London: Dulwich Centre Publications; 2000.\u003c/li\u003e\n\u003cli\u003eWhite M. Maps of Narrative Practice. New York: WW Norton; 2007.\u003c/li\u003e\n\u003cli\u003eHigbed L, Fox JRE. Illness perceptions in anorexia nervosa: A qualitative investigation. British Journal of Clinical Psychology. 2010;49(3):307\u0026ndash;25. https://doi.org/10.1348/014466509x454598\u003c/li\u003e\n\u003cli\u003ePugh M. The internal \u0026lsquo;anorexic voice\u0026rsquo;: a feature or fallacy of eating disorders? Advances in Eating Disorders. 2016;4(1):75\u0026ndash;83. https://doi.org/10.1080/21662630.2015.1116017\u003c/li\u003e\n\u003cli\u003eMedway M, Rhodes P. Young people\u0026rsquo;s experience of family therapy for anorexia nervosa: a qualitative meta-synthesis. Advances in Eating Disorders. 2016; 4(2):189-207.\u003c/li\u003e\n\u003cli\u003eVoswinkel MMH, Rijkers C, Van Delden JJM, Elburg A. Externalizing your eating disorder: a qualitative interview study. Journal of Eating Disorders. 2021;9(1)1-2. https://doi.org/10.1186/s40337-021-00486-6\u003c/li\u003e\n\u003cli\u003eGregertsen EC, Mandy W, Serpell L. The egosyntonic nature of anorexia: an impediment to recovery in anorexia nervosa treatment. Frontiers in Psychology. 2017;8:2273. https://doi.org/10.3389/fpsyg.2017.02273\u003c/li\u003e\n\u003cli\u003eWufong E, Rhodes P, Conti J. \u0026ldquo;We don\u0026rsquo;t really know what else we can do\u0026rdquo;: Parent experiences when adolescent distress persists after the Maudsley and family-based therapies for anorexia nervosa. 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Psychological Medicine. 2008;38(9):1371\u0026ndash;3. https://doi.org/10.1017/s0033291708003796\u003c/li\u003e\n\u003cli\u003eZaitsoff SL, Pullmer R, Cyr M, Aime H. The Role of the Therapeutic Alliance in Eating Disorder Treatment Outcomes: A Systematic review. Journal of Eating Disorders. 2014;23(2):99\u0026ndash;114. https://doi.org/10.1080/10640266.2014.964623\u003c/li\u003e\n\u003cli\u003eLonergan K, Whyte A, Ryan C. Externalisation in family‐based treatment of anorexia nervosa: The therapist\u0026rsquo;s experience. Journal of Family Therapy. 2021;44(3):351\u0026ndash;69. https://doi.org/10.1111/1467-6427.12380\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Thematic analysis: a practical guide. London: Sage Publications; 2021. \u003c/li\u003e\n\u003cli\u003eFairburn CG, Beglin SJ. Assessment of eating disorder psychopathology: Interview or self-report questionnaire? 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Patients\u0026rsquo; experiences and perceptions of recovering from anorexia nervosa while having contact with psychiatric care: a literature review and narrative synthesis of qualitative studies. Issues in Mental Health Nursing. 2021;42(8):709-19. https://doi.org/10.1080/01612840.2020.1847222\u003c/li\u003e\n\u003cli\u003eSheridan G, McArdle S. Exploring patients\u0026rsquo; experiences of eating disorder treatment services from a motivational perspective. Qualitative Health Research. 2016;26(14):1988\u0026ndash;97. https://doi.org/10.1177/1049732315591982\u003c/li\u003e\n\u003cli\u003eRance N, Moller N, Clarke V. \u0026lsquo;Eating disorders are not about food, they\u0026rsquo;re about life\u0026rsquo;: Client perspectives on anorexia nervosa treatment. Journal of Health Psychology. 2015;22(5):582\u0026ndash;94. https://doi.org/10.1177/1359105315609088\u003c/li\u003e\n\u003cli\u003eConti J, Joyce C, Hay P, Meade T. \u0026ldquo;Finding my own identity\u0026rdquo;: a qualitative meta-synthesis of adult anorexia nervosa treatment experiences. BMC Psychology. 2020; 8(1):1-4. https://doi.org/10.1186/s40359-020-00476-4\u003c/li\u003e\n\u003cli\u003eGraham MR, Tierney S, Chisholm A, Fox JRE. Perceptions of the \u0026ldquo;anorexic voice\u0026rdquo;: A qualitative study of health care professionals. Clinical Psychology \u0026amp; Psychotherapy. 2019;26(6):707\u0026ndash;16. https://doi.org/10.1002/cpp.2393\u003c/li\u003e\n\u003cli\u003eFox JRE, Dean M, Whittlesea A. The experience of caring for or living with an individual with an eating disorder: A meta-synthesis of qualitative studies. Clinical Psychology \u0026amp; Psychotherapy. 2015;24(1):103\u0026ndash;25. https://doi.org/10.1002/cpp.1984\u003c/li\u003e\n\u003cli\u003eHay P, Cho K. A qualitative exploration of influences on the process of recovery from personal written accounts of people with anorexia nervosa. Women \u0026amp; Health. 2013;53(7):730\u0026ndash;40. https://doi.org/10.1080/03630242.2013.821694\u003c/li\u003e\n\u003cli\u003eEaton CM. Eating Disorder Recovery: A Metaethnography. Journal of the American Psychiatric Nurses Association. 2019;26(4):373\u0026ndash;88. https://doi.org/10.1177/1078390319849106\u003c/li\u003e\n\u003cli\u003eSerpell L, Treasure J, Teasdale J, Sullivan V. Anorexia nervosa: friend or foe?. International Journal of Eating Disorders. 1999;25(2):177-86. https://doi.org/10.1002/(SICI)1098-108X(199903)25:2\u0026lt;177::AID-EAT7\u0026gt;3.0.CO;2-D\u003c/li\u003e\n\u003cli\u003eWildes JE, Ringham R, Marcus MD. Emotion avoidance in patients with anorexia nervosa: Initial test of a functional model. International Journal of Eating Disorders. 2010;43(5):398\u0026ndash;404. https://doi.org/10.1002/eat.20730\u003c/li\u003e\n\u003cli\u003eMantilla EF, Clinton D, Birgeg\u0026aring;rd A. The unsafe haven: Eating disorders as attachment relationships. British Journal of Medical Psychology. 2018;92(3):379\u0026ndash;93. https://doi.org/10.1111/papt.12184\u003c/li\u003e\n\u003cli\u003ePugh M, Waller G, Esposito M. Childhood trauma, dissociation, and the internal eating disorder \u0026lsquo;voice\u0026rsquo;. Child Abuse \u0026amp; Neglect. 2018;86:197-205. https://doi.org/10.1016/j.chiabu.2018.10.005\u003c/li\u003e\n\u003cli\u003eWilliams K, King J, Fox JRE. Sense of self and anorexia nervosa: A grounded theory. British Journal of Medical Psychology. 2015;89(2):211\u0026ndash;28. https://doi.org/10.1111/papt.12068\u003c/li\u003e\n\u003cli\u003eScott N, Hanstock TL, Thornton C. Dysfunctional self-talk associated with eating disorder severity and symptomatology. Journal of Eating Disorders. 2014;2(1):1-1. https://doi.org/10.1186/2050-2974-2-14\u003c/li\u003e\n\u003cli\u003eWright K, Hacking S. An angel on my shoulder: a study of relationships between women with anorexia and healthcare professionals. Journal of Psychiatric and Mental Health Nursing. 2011;19(2):107\u0026ndash;15. https://doi.org/10.1111/j.1365-2850.2011.01760.x\u003c/li\u003e\n\u003cli\u003eWetzler S, Hackmann C, Peryer G, Clayman K, Friedman DD, Saffran K, et al. A framework to conceptualize personal recovery from eating disorders: A systematic review and qualitative meta‐synthesis of perspectives from individuals with lived experience. International Journal of Eating Disorders. 2020;53(8):1188\u0026ndash;203. https://doi.org/10.1002/eat.23260\u003c/li\u003e\n\u003cli\u003eMalson H, Bailey L, Clarke S, Treasure J, Anderson G, Kohn M. Un/imaginable future selves: A discourse analysis of in-patients\u0026rsquo; talk about recovery from an \u0026lsquo;eating disorder.\u0026rsquo; European Eating Disorders Review. 2010;19(1):25\u0026ndash;36. https://doi.org/10.1002/erv.1011\u003c/li\u003e\n\u003cli\u003eLevine M. Communication challenges within eating disorders: What people say and what individuals hear. In: Jauregui-Lobera I, editor. Eating disorders: A paradigm of the biopsychosocial model of illness. Spain: IntechOpen. 2017;239-72. https://doi.org/10.5772/65305\u003c/li\u003e\n\u003cli\u003eStiles‐Shields C, Bamford B, Touyz S, Grange DL, Hay P, Lacey H. Predictors of therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa. Journal of Eating Disorders. 2016;4(1):1-7. https://doi.org/10.1186/s40337-016-0102-6\u003c/li\u003e\n\u003cli\u003eFederici A, Kaplan AS. The patient\u0026rsquo;s account of relapse and recovery in anorexia nervosa: a qualitative study. European Eating Disorders Review. 2007;16(1):1\u0026ndash;10. https://doi.org/10.1002/erv.813\u003c/li\u003e\n\u003cli\u003eJohnston MS. When madness meets madness: Insider reflections on doing mental health research. International Journal of Qualitative Methods. 2019;18. https://doi.org/10.1177/1609406919835356\u003c/li\u003e\n\u003cli\u003eAdkins L, May T, (ed.). Reflexivity and the Politics of Qualitative Research. In Qualitative Research in Action. London, Thousand Oaks and New Delhi: Sage Publications Ltd. 2002. https://doi.org/10.1080/09540261.2019.1593112\u003c/li\u003e\n\u003cli\u003eTaylor J. The intimate insider: Negotiating the ethics of friendship when doing insider research. Qualitative research. 2011;11(1):3-22. https://doi.org/10.1177/1468794110384447\u003c/li\u003e\n\u003cli\u003eByrne D. A worked example of Braun and Clarke\u0026rsquo;s approach to reflexive thematic analysis. Quality \u0026amp; quantity. 2022;56(3):1391-412. https://doi.org/10.1007/s11135-021-01182-y\u003c/li\u003e\n\u003cli\u003eLindenmeyer A, Hearnshaw H, Sturt J, Ormerod R, Aitchison G. Assessment of the benefits of user involvement in health research from the Warwick Diabetes Care Research User Group: a qualitative case study. Health Expectations. 2007;10(3):268-77. https://doi.org/10.1111/j.1369-7625.2007.00451.x\u003c/li\u003e\n\u003cli\u003eThompson J, Bissell P, Cooper C, Armitage CJ, Barber R. Credibility and the \u0026lsquo;professionalized\u0026rsquo; lay expert: Reflections on the dilemmas and opportunities of public involvement in health research. Health. 2012;16(6):602-18. https://doi.org/10.1177/13634593124410\u003c/li\u003e\n\u003cli\u003eHalbeisen G, Brandt G, Paslakis G. A plea for diversity in eating disorders research. Frontiers in Psychiatry. 2022;13:820043. https://doi.org/10.3389/fpsyt.2022.820043\u003c/li\u003e\n\u003cli\u003eAcle A, Cook BJ, Siegfried N, Beasley T. Cultural considerations in the treatment of eating disorders among racial/ethnic minorities: A systematic review. Journal of Cross-Cultural Psychology. 2021;52(5):468-88. https://doi.org/10.1177/0022022121101766\u003c/li\u003e\n\u003cli\u003eThapliyal P, Hay P, Conti J. Role of gender in the treatment experiences of people with an eating disorder: a metasynthesis. Journal of eating disorders. 2018;6(1):1-6. https://doi.org/10.1186/s40337-018-0207-1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"anorexia nervosa, anorexia voice, eating disorder voice, externalisation, recovery, qualitative, thematic analysis","lastPublishedDoi":"10.21203/rs.3.rs-3906525/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3906525/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Many individuals perceive anorexia nervosa (AN) as a part of their personal identity. Externalisation involves making the “problem” a separate entity, external to the individual. It is an attitude taken by the client and family, stimulated by the therapist to build engagement with treatment and supportive relationships around the individual. Externalisation is used in NICE recommended treatments for AN, however there is a paucity of research exploring the therapeutic effects of this approach. This research aims to address this gap by exploring the role of externalisation in treatment for AN to elicit an understanding of how this practice can help and hinder recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This qualitative study used a reflexive thematic analysis. Thirteen adults with a current and/ or past diagnosis of AN participated in semi-structured interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e: Participants described their experience of externalisation as a journey which is depicted by five themes. ‘Separation’ portrays the separation of the individual’s internal dialogue from the ‘self’. ‘Making sense of AN’ describes the experience of language and exercises used to separate AN. ‘A third entity in relationships’ illustrates the impact of externalisation on relationships. ‘A relationship with AN’ elucidates the use of externalisation to explore the function and effects of the individual’s relationship to AN. ‘Managing AN’ explains the experience of a continued relationship with the externalised AN entity post-treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The notion of separating one’s internal dialogue from one’s concept of self may initially be rejected. As the individual develops trust in the therapist, they may begin to realise two sides within them, the “healthy self” (HS) and the “anorexia voice” (AV). However, social-cultural discourses around eating contribute to ambiguity during the dichotomous categorisation of thoughts. Externalising practices were most helpful when led by the individual using their own experience-near language. Externalisation which did not permit the individual to feel seen as a person beyond AN was hindering to recovery. Therapists, treatment teams and family members should be cognisant of the emotional effects of language used to externalise AN. Future research should elicit an understanding of the experience of externalisation among a diverse sample of young people and families.\u003c/p\u003e","manuscriptTitle":"Experiences of externalisation in recovery from anorexia nervosa: a reflexive thematic analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-02 13:48:11","doi":"10.21203/rs.3.rs-3906525/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-17T03:13:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-04T20:34:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3aa1926b-c9a0-4344-96aa-9414e688d123","date":"2024-02-04T10:12:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-04T03:30:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-31T13:02:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-31T13:02:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Eating Disorders","date":"2024-01-28T18:02:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ff25f553-5515-4b72-adae-db11edf80677","owner":[],"postedDate":"February 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-14T16:00:17+00:00","versionOfRecord":{"articleIdentity":"rs-3906525","link":"https://doi.org/10.1186/s40337-024-01087-9","journal":{"identity":"journal-of-eating-disorders","isVorOnly":false,"title":"Journal of Eating Disorders"},"publishedOn":"2024-10-07 15:57:15","publishedOnDateReadable":"October 7th, 2024"},"versionCreatedAt":"2024-02-02 13:48:11","video":"","vorDoi":"10.1186/s40337-024-01087-9","vorDoiUrl":"https://doi.org/10.1186/s40337-024-01087-9","workflowStages":[]},"version":"v1","identity":"rs-3906525","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3906525","identity":"rs-3906525","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}