Could a parent’s rage at ‘ED’ slow down progress?

Love your child… hate the eating disorder?

Early on in eating disorder treatment, your clinician may have introduced you to 'externalizing':

'Look, your child didn't choose this illness. They need your love and acceptance to get through it. If your child feels judged and blamed, research indicates that's going to hold back their recovery. So when you hate what your child is doing or saying, see it as coming not from them, but from an external entity. You or your child might give it a name even, like 'ED', or 'Ana' or 'Voldemort'."

If that's been working really well for you and for your child, then don't change anything — go do something lovely instead of reading this. But if your child is protesting, "I'm me !!! See me !!!" or if you yourself are getting frustrated, then I want to share some subtle aspects of externalizing which some parents have found useful.

In Chapter 14 of my book I say a lot more on externalizing, and here I'm going to focus on just one single facet:

When you present 'ED' as a hostile separate entity, does this succeed in your child perceiving your love and support, or does it inadvertently do the opposite?

Can your child sense your love and support?

We parents are caught in a whirlwind of emotions, understandably. We've never before experienced such grief, fear, exhaustion, confusion, uncertainty. Our dear child seems to have disappeared. We want to weep, we want to scream.

We achieve more when in spite of all this our child perceives that we're loving, supportive, confident, trustworthy.

So the question is: does externalizing succeed in helping you project these positives to your child?

In theory, yes, because you can redirect all your heartbreak, your fears, your rage, towards this metaphorical 'ED':

• Some see 'ED' as a demon to be slayed, and it gives them the fighting energy to keep going.
• It can also help them be firm: is it my child who's saying they hate pasta, or a hijacker holding a gun to their head?
• And it can help them see through their child's ambivalence: when a young person whispers, "Do I really have to eat this?" they may be asking for ammunition against their internal bully.

Yet some parents have noticed that in spite of these excellent principles, their child responds to externalizing talk with extra hostility or shut-down.

Instead of serving connection, the externalizing model — or some aspect of how it's been taught — is increasing the disconnect.

Happily, parents find ways around this problem, as I will describe here. As always, use what's helpful and leave the rest.

First, let's look a little more at the reasons clinicians teach externalizing.

Why see your child as separate to the eating disorder?

Mainly, because we get frustrated and scared and exhausted, so it would be just too easy to shout and scream, accuse, blame, criticize, or get all passive-aggressive.

We're only human, and sometimes that's exactly what we do, especially when we haven't yet received expert support. We can get away with many mistakes, thankfully. We have years of parent-child love in the bank account.

But when we do the cold or shouty stuff rather too frequently (psychologists call this high 'expressed emotion'), it hinders recovery. Plus, it's unfair on our children: they didn't choose to get an eating disorder.

"By separating the illness from the adolescent, it helps the parents to know that their battles are about an illness and not with their kid"

Daniel Le Grange, co-author of the FBT manual, in this webinar

You'll find externalization in both the FBT (Family-Based Treatment) manual and the Maudsley Service manual. One of the goals is to help parents be supportive, non-judgemental, and effective.

"Used therapeutically as a metaphorical concept, externalising the effects of the illness can helpfully dilute the impact of conversations that focus on emotions such as guilt and blame"

Maudsley Service manual

Externalizing may also be a therapeutic tool for the person with an eating disorder. It has to be used in a sensitive way. If it's imposed in a heavy-handed manner, the person tends to reject it. They feel un-seen, misunderstood, alienated and patronized ('I am me!!! Stop telling me I have an 'ED voice!!!').

Externalizing can also give parents clarity when their child pleads for the lasagne to be replaced with lettuce. In the early days when you are learning as fast as you can, externalizing provides a simple guide (If it comes from 'ED' then I say 'No'). With time you may need more nuance and the confidence to risk-assess.

"If we understand externalisation and use the concept collaboratively it can be so helpful in reducing guilt and blame. But used glibly or too forcefully by family or therapist when it makes little or no sense to the patient, it can be really unhelpful."

Esther Blessit, co-author of the Maudsley Service manual

Conveying our love and support

Back to the point of this article: we want our child to feel loved and accompanied rather than judged. That will help them cope emotionally, and manage meals and weight gain and changing behaviours and habits and learning emotional regulation… the whole stuff of treatment.

Some parents are sustained by a strong image of a hateful 'ED' while still conveying to their child words and body-language that are connecting and loving.

Some want to keep the imagery but sense they need to tweak their language for their compassion to successfully come across.

"It's not: 'No negotiation, this is what we have to do, and be quiet, and we are just this 'brick wall' that will take no debate, no discussion’"

Daniel Le Grange in this webinar on what FBT is and is not

Sometimes we use language focused on 'beating ED'. It's good to check how our child perceives this: for some this validates their own sense of an internal struggle, while others experience our language as alienating. As Daniel Le Grange, co-author of the FBT (Family-Based Treatment) manual, wrote to me :

"It creates the impression of setting up an adversarial stance ‘against’ the adolescent and doesn’t sound supportive and empathic toward the adolescent. Parental persistence should go hand-in-hand with unrelenting support and understanding for the adolescent's struggle."

"But I'm only cross at 'ED'. I love you."

The way some of us have been taught to externalize, we have assumed that the model shields our child from our negative emotions. But the authors of the treatment manuals see things in a more nuanced way:

"it's hard for your anger at the illness not to be perceived by your child as anger for her"

'Help your teenager beat an eating disorder', Lock & Le Grange's FBT book for parents

So it can be worth checking whether, in spite of our loving intentions, our child is internalising the animosity we feel towards 'ED'.

How might externalizing not work as intended?

My child says, "I don't like pasta."

I can say to myself, "That's that nasty, cheating, lying ED talking. I won't be beaten." Unless I'm a good actor, my mouth tightens, my eyes become hard. I'm trying to think of my next step to fight the monster.

Perhaps my child senses my emotions and doesn't comprehend that I actually love her. She whimpers (or yells), "You hate me!" and pushes the plate away.

I've not said anything, and yet my child has perceived my animosity. What can I do now?

I can go further with the externalizing metaphor: "I don't hate you! I hate ED! I hate this vile monster that's hijacked you. Look, now it's denying you the pasta that you need. It's a bully!"

My guess is that for a young person who's in a state of fight, flight or freeze, they only perceive the animosity. It doesn't make sense to them that we can love them while hating a big part of them (if it does feel like a big part of them). They can't rationalise that our body language is not a reflection of how we feel about them. Let's remember that they are extra-sensitive at present, and extra-likely to interpret even neutral facial expressions as critical (there's research from Janet Treasure on that which I hope to find a link to soon).

Think of times you've been near someone who is furious. Through gritted teeth, they tell you, 'It's not you! It's this *$**^** can opener that doesn't work!' Don't you still feel tense? Don't you still get defensive?

From the Maudsley Service manual for child and adolescent eating disorders (2016):

"If used too liberally and without care, anorexia can become described in increasingly dramatic and fearful terms which for some patients cannot easily be separated from their core sense of self […] When the metaphor becomes over-used and relied upon too readily as a vehicle for the distress and anger caused by the illness, delineation between overt blaming of anorexia and blaming of the patient can become blurred."

Options when your child perceives a disconnect

If our child is misunderstanding our intentions, if they feel disconnection instead of connection while we're separating them from the eating disorder, what can we do?

• We can keep explaining the two are separate: "It's the illness I hate. We're going to beat it. I love you."
• We can check our body language and our words. So while we're privately raging against 'ED' we succeed in only showing empathy.
• We can also go one step further: steer away from the adversarial imagery, and dive deep into a stance of empathy. With my daughter, that's how improvements started rolling in. The connecting words and body language 'spoke' to her more effectively, and I got more resilience from it too. I'll say more on this now.

Parents who veered away from externalizing

Some parents, including myself, have found that they do a better job when they move away from externalizing and instead, focus one hundred percent on empathy.

What's really going on for my child? What are their fears, their internal contradictions, their needs? How can I find the best words and body language to connect, so that I can then support my child to achieve a difficult task?

This is not everyone's cup of tea. My intention is only to give you tools you might not have come across before.

“I kept reading that I had to be stronger than the eating disorder. But I realised this was making me harsh and robotic: I was switching off from my child.”

A parent

Parents who have steered away from externalizing describe how, when they're filled with animosity to 'ED', they're in an oppositional state, with less bandwidth for connection. They've shifted their focus from being 'against' ED, to being wholeheartedly 'for' their child. They couldn't convincingly do both at once.

Here is one mother's 'Aha' moment:

“Part of me has been judging my daughter. And now I feel that I 'get it'. She has not been taken over by a monster that I’m trying to vanquish! She is doing her best to manage the intense volume of noise within her head. Already this has reset our course. I am really getting the importance of connection, the relationship and compassion."

I talk more about this in this clip from my Bitesize audio collection:

Examples of dialogue

So there you have it. A whole range of possibilities which may or may not work in your situation. How might those look in practice? Here are some examples using responses that are more or less connecting.

'I'm too full'

Brisk externalizing response:

'That's ED tricking you. I don't negotiate with a terrorist.'

More focus on connection:

'I'm so sorry you feel too full. It's a horrible feeling. May I stroke your arms? Let's have a stretch and a wiggle… And now keep going with the pasta please.'

Keeping it 'real' might help some people:

'It's normal you should feel that. An eating disorder can mess with your sensations. This is really what you need. Keep going, darling.'

'I need to go to the gym'

Brisk externalizing response:

'The doctor said "No exercise". I don't negotiate with ED!'

More focus on connection:

'Oh darling, I don't blame you for wanting to go to the gym. You've got such a community there. I wonder if you hope the gym will make you feel better? …. Sadly, that's not a wise move right now. Let's find something else to occupy you.'

With a some nuanced externalizing (don't we all have an internal critic?!):

'I'm wondering if that old internal critic is flaring up again, telling you you're lazy?'

'I am disgusting and hate myself'

Brisk externalizing response:

'That's Ana talking. I don't talk with Ana'

More focus on connection:

'That sounds so painful, sweetheart. I imagine it's quite exhausting to feel that way. May I give you a hug? It's common that at this stage your body doesn't feel right to you. These feelings will pass. I'm with you. Let's look for some kitten videos and change the mood.'

Using a person's own metaphors:

'In the past you've said that Ana was bullying you. Is that what's happening right now?'

'It's really helping, when we eat in front of the TV'

Brisk externalizing response:

'No more TV. This family has meals at the table, and I'm not going to give the eating disorder the satisfaction of controlling everything'

More focus on connection:

'That's good to hear. I had noticed that too. I'm glad we've found something that make your meals a little easier for now.'

With a some nuanced externalizing (don't we all have conflicting parts?):

'I'd enjoy that, and at the same time I'm worried that when we last did this you put food down the back of the sofa. Is there possibly a part of you that's driving you to do that again?'

Either way, externalizing should not mean you are a doormat

One last point. If you blame 'ED' for everything, you might lose sight of the fact your child does have some agency, as in this example:

'I'm sorry I tried to kick you at lunchtime'

Compare:

'Don't even mention it. It was ED, not you.'

with

'Thank you. I see your care and how you want to mend things with me. Shall we think of ways you can manage your emotions another time — perhaps with our help?'

"Without the benefit of these conversations families might become muddled by a potential message through externalising conversations which could be heard as 'she can’t help it, it’s the anorexia' […] An externalising perspective does not mean that the patient has lost responsibility for acting within acceptable limits

(from the Maudsley Service manual)

Your style will be different from mine. The main thing is, can your child perceive you as non-blaming while you're also making wise decisions and seeing them through?

'Slaying the beast' or 'Walking alongside your child'?

To conclude, do you see yourself as a warrior in a war-zone, a lifeguard on a rescue mission, or perhaps as a coach walking side by side with your child through fire?

How does that color your body language, your choice of words, and your child's perceptions?

There is no right or wrong imagery. Different visions help us at different times. Whatever helps us be compassionate and persistent, courageous and present to our child.

"I keep thinking: connection connection connection and keep turning up with food."

A parent

For more on this topic

There's a lot more behind externalizing than I've said here, and many ways in which externalizing can be helpful or unhelpful to you and to your child.

Chapter 14 of my book covers many more aspects of externalizing, and is full of endnotes for you to read what others say about it.

And there are many short audios on the topic in my Bitesize audio collection.

For more examples of communication which can work whether or not you're using the externalizing model, lots of Bitesize audios, and you could jump to Chapter 13 and 14 of my book. I also do online workshops.

The Maudsley Service manual for child and adolescent child and adolescent eating disorders includes excellent discussions on the use and pitfalls of externalizing. Ivan Eisler, Mima Simic, Esther Blessit, Liz Dodge and team (2016)

The FBT treatment manual shows how an FBT therapist uses externalizing, especially when parents criticize their child (Lock, Le Grange)

And I'm glad to see that the creators of both approaches are now broadening externalisation to include neurobiology and the effects of starvation. In other words (my words), "Don't yell at your child — they're not in full control of their thoughts and behaviours because of how their brain and body are operating right now".