Love your child… hate the eating disorder?
Have you been taught, like most families faced with an eating disorder, to 'externalize' the eating disorder? To separate your child from the eating disorder?
Some parents understand this as a free pass to hate, really hate, a mythical eating disorder monster, that kidnapper of innocent children, that beast ED, that demon Voldemort, that cowardly, cheating, lying Ana.
That can feel rather therapeutic. Let it all out, rage, have a good rant with fellow parents who really 'get it'. Goodness knows we need understanding for our fears and frustrations along this extremely demanding journey. And at the same time…
I'm going to propose two ways in which this might not be helping either you or your child. Then I'll give you examples of dialogue, with and without war-like externalizing.
As always, check it out, discuss with your clinical team, take what's useful and leave the rest.
How might this fury at 'ED' hinder progress?
A. If in the presence of your child, you are displaying animosity against 'ED', your child may feel the anger is directed at them, however much you tell them you love them. Especially so if your expression is intense — shouty, sarcastic or frosty.
B. If you are regularly seeing the illness as a monstrous beast to be slayed, check what it does to your mind and mood. Is it maintaining you in a state of fear and fight? Is it getting in the way of your wise, intelligent self?
I'll say more on these two aspects. First, a few words on why clinicians invite parents to externalize.
Mainly, because we get frustrated and scared and exhausted, so it's just too easy to shout and scream, accuse, blame, criticize. When we do this rather too often (psychologists call this high 'expressed emotion'), it hinders recovery. Plus, it's terribly 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. With parents the intention is to make us 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 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 gives 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.
Separating the eating disorder from a person is also a therapeutic tool, to be used in a sensitive way. If it's imposed on a young person in a heavy-handed manner, they often hate it. They feel un-seen, misunderstood, alienated and patronized ('I am me!!! Stop telling me I have an 'ED voice!!!').
"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
Are you displaying animosity against 'ED'?
In your mind, do you anthropomorphise the illness as a hateful hijacker, a lying, cheating monster, an evil demon? Do you think in terms of slaying it, beating it, eradicating it? And is that how you talk?
Externalizing was not intended as a free pass to emote about the eating disorder in the presence of our child. It does not give us a green light to mutter 'I hate ED!!!!' at the dinner table. Even less so to yell it.
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? In the same say, when we're telling our child that our fight is 'only against ED', they'd have to be in a remarkably good mental state to not absorb our animosity.
Daniel Le Grange, co-author of the FBT (Family-Based Treatment) manual, wrote to me in relation to some words parents use:
"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."
"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
Here's a test: when you talk about ED, ANA, or Voldermort, do you think your child's body reacts with a helpful sense of connection… or with fear? Usually, fear is not a useful emotion to pile onto our child.
If you 'hate ED', can your child feel your love?
"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
I say more in this clip from my Bitesize audio collection: If you hate 'ED', does your child feel your love?
And here is more 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."
Are you so focused on the evil 'ED' that you're switching off from your child?
“I kept reading on parents’ groups 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
If we're filled with animosity to 'ED', we're probably in an oppositional state, with less bandwidth for connection. When we have an intense focus on being 'against' ED, it's good to check if we can also be wholeheartedly 'for' our child.
Maybe you can relate to this mother's 'Aha' moment, described below:
“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."
Helpful imagery: 'Slaying the beast' or 'Walking alongside your child'?
Let's turn to what works for you, at present? I'm talking about what's in the privacy of your own mind.
Do you see yourself as a warrior in a war-zone, a lifeguard on a rescue mission, or perhaps as a coach walking through fire side by side with your child?
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.
Examples of dialogue: with and without adversarial externalizing
Some parents wonder how they can respond to their child without a brisk, 'I'm not talking about it. That's ED talking!' So here are some examples (and you'll have your own perfectly wonderful style).
'I'm too full'
'That's ED tricking you. I don't negotiate with a terrorist'
'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.'
'I need to go to the gym'
'The doctor said "No exercise". I don't negotiate with that lying, manipulating ED!'
with this possible reply:
'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.'
'I am disgusting and hate myself'
'That's Ana talking. I don't talk with Ana'
with one of many possible opportunities to connect:
'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.'
'It's really helping, when we eat in front of the TV'
'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'
with this possibility:
'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.'
Either way, don't become 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'
'Don't even mention it. It was ED, not you.'
'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 may be different from mine. The main thing is, can you be non-blaming and make wise decisions and see them through?
For more on this topic
"I keep thinking: connection connection connection and keep turning up with food."A parent
There's a lot more behind externalizing than I've said here.
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)
A very thorough paper about externalizing: 'Alienating patients from the ‘Anorexic Self' by Kelly Bemis Vitousek.