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Using Narrative Therapy to Treat Eating Disorder Not Otherwise Specified

Ned Scott, Tanya L. Hanstock and Lisa Patterson-Kane
Clinical Case Studies 2013 12: 307 originally published online 7 May 2013
DOI: 10.1177/1534650113486184
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research-article2013

CCS12410.1177/1534650113486184<italic>Clinical Case Studies</italic>Scott et al.

Article

Using Narrative Therapy to

Treat Eating Disorder Not
Otherwise Specified

Clinical Case Studies

12(4) 307321
The Author(s) 2013
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DOI: 10.1177/1534650113486184
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Ned Scott1, Tanya L. Hanstock1 and Lisa Patterson-Kane1

Abstract
Eating disorders have proved resistant to therapy with high relapse rates. Enhanced cognitive
behavior therapy (CBT-E) is the favored treatment of choice but has been criticized for placing
a similar emphasis on controlling eating behavior as the psychopathology it seeks to counter. In
contrast, narrative therapy focuses on the development of an anti-eating disorder lifestyle and
values. Evidence for this approach primarily consists of informal case study material. This case
study describes a 28-year-old woman with a recurring history of anorexia nervosa, who selfreferred to a university psychology clinic, due to fears of imminent relapse. The client received
10 sessions of narrative therapy and made significant progress in externalizing her eating
disorder, in lessening her adherence to the ascetic values underpinning it, and in developing/
expressing her non-eating disorder character and values. This case study provides evidence
of the potential effectiveness of narrative therapy and contains valuable learning for clinicians
regarding its implementation.
Keywords
narrative therapy, eating disorders, EDNOS, anorexia nervosa

1 Theoretical and Research Basis for Treatment

The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR;
American Psychiatric Association [APA], 2000) lists two specific diagnoses of eating disorder:
anorexia nervosa (AN) and bulimia nervosa (BN). DSM-IV-TR also includes a residual diagnosis
of eating disorders not otherwise specified (EDNOS) to capture those individuals who meet most
but not all of the criteria for a specific AN or BN diagnosis. Examples include individuals who
meet all the criteria for AN other than sufficiently low weight or, in postmenarcheal females, the
cessation of menses; individuals who satisfy the criteria for BN but with lower than the required
frequencies; and individuals with binge-eating disorder (APA, 2000).
Eating disorders are predominantly associated with women in Western industrialized countries, where there is a strong cultural emphasis on thinness as the feminine ideal (Nasser &
Katzman, 2003). At least 9 out of 10 patients presenting with AN and BN are females. Even in
1University

of New England, Armidale, New South Wales, Australia

Corresponding Author:
Tanya L. Hanstock, School of Behavioural, Cognitive and Social Sciences, University of New England,
Armidale, NSW 2351, Australia.
Email: thansto2@une.edu.au

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Clinical Case Studies 12(4)

these populations, lifetime prevalence rates are low: DSM-IV-TR reports current rates of approximately 0.5% for AN and 1% to 3% for BN (APA, 2000). However, it is estimated that as many
as 50% to 60% of adult eating disorder outpatients fall into the EDNOS category (Fairburn,
2008). Substantially greater prevalence rates have been reported among certain specialized populations. Among female college students, estimates of current prevalence for all forms of eating
disorder range from 8% to 17% (Eisenberg, Nicklett, Roeder, & Kirz, 2011). Eisenberg et al.
(2011) themselves found that in a random sample of women students, 14% of undergraduates and
9% of graduates recorded positive screens for an eating disorder using the SCOFF screening
instrument developed by J. F. Morgan, Reid, and Lacey (1999). It consists of five questions,
which provide the basis of the SCOFF acronym. Questions are about making oneself Sick due to
feeling uncomfortably full, the loss of Control over eating, the loss of more than One stone over
a 3-month period, believing one is Fat despite others contrary statements, and feeling that Food
dominates ones life.
Currently, the prognosis for eating disorders is quite poor. In some cases of AN, particularly
those associated with early onset, a single episode is followed by a full recovery. In most
instances, however, the course of these disorders is either chronic or follows a fluctuating pattern
between (partial) remission and relapse (APA, 2000). AN carries a mortality rate of at least 10%,
which is one of the highest of all mental disorders. Between a quarter and a third of these deaths
are attributable to suicide (Harris & Barraclough, 1998; Maj, Halmi, Lopez-Ibor, & Sartorius,
2003), whereas the rest are due to the physical consequences of starvation and malnutrition (Keel
et al., 2003).
The evidence base for eating disorder treatments in adults is somewhat lacking, being primarily related to the use of cognitive behavioral therapy (CBT) to treat BN. CBT is more effective
than antidepressant medication, nonspecific psychotherapy, and pure behavior therapy (Wilson
& Fairburn, 2007). Interpersonal therapy (IPT) has been found to be equally effective over the
long term but CBT remains the treatment of choice because it is faster acting and has a wider
evidence base (Wilson & Fairburn, 2007). For adults with AN, Wilson and Fairburn (2007) argue
that the research is inadequate to support an evidence-based recommendation. Nevertheless, they
report that arguments for there being a common pathology transcending all eating disorders have
led to CBT being regarded as the adult treatment of choice. Research into the treatment of patients
with EDNOS has focused almost exclusively on that subset of patients with binge-eating disorder
(Wilson & Fairburn, 2007).
More recently, an enhanced and more flexible form of the treatment (enhanced cognitive
behavior therapy [CBT-E]) has been developed. CBT-E operates through the construction of a
personalized formulation that identifies those factors responsible for the development and maintenance of the eating disorder. While the core CBT-based treatment is designed to address common eating disorder pathology, a variety of optional modules exist to treat other mechanisms
(such as perfectionism), which help sustain the disorder (Fairburn, Cooper, Shafran, Bohn, &
Hawker, 2008). In addition to improved results in treating BN, CBT-E has also been shown to be
effective in treating patients with EDNOS (Fairburn et al., 2009).
Even with these favored treatments, outcomes are at best moderate. For example, with CBT
and IPT, only approximately 40% of BN patients have ceased binge eating and purging 12 months
after treatment cessation (Wilson & Fairburn, 2007). Twelve years post treatment, approximately
33% of patients with BN and 21% to 27% of patients with AN still qualify for an eating disorder
diagnosis (Berkman, Lohr, & Bulik, 2007). Similarly, Von Holle et al. (2008) found that, 10 years
post treatment, only 10% to 11% of AN and BN patients were completely symptom-free. One
criticism of treatments for eating disorders is that the majority place a similar emphasis on the
importance of weight and of controlling eating behavior as the psychopathology they are designed
to counter (Maisel, Epston, & Borden, 2004).

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In contrast, narrative therapy focuses on externalizing the eating disorder and exposing its
tactics, while encouraging the development of an anti-eating disorder lifestyle and values (Maisel
et al., 2004). Externalization involves viewing the eating disorder as an entity whose existence is
quite distinct from the sufferer (A. Morgan, 2000). The problem becomes the problem, not the
person (White, 2007, p. 9). Therapy then focuses on deconstructing the dominant narrative that
is maintaining the eating disorders hold on the individual: the goal being to replace this story
with a richer alternate or preferred narrative based on those values and ambitions that have been
subjugated by the eating disorder (A. Morgan, 2000).
Evidence in support of this approach is primarily limited to informal case study material in
which clients describe changes in attitude toward their eating disorder, and in their ability to
resist its influence (e.g., Epston, 1999; Maisel et al., 2004; Nylund, 2002). However, a recent
small-scale study on the use of narrative therapy in a group context, with women who identified
themselves as having long-term problems with eating disorders (between 5 and 23 years) and
comorbid depression, demonstrated reductions in levels of depression and eating disorder risk as
measured by the Eating Disorder Inventory3 (EDI-3; Weber, Davis, & McPhie, 2006).

2 Case Introduction
The client, Victoria (all identifying details have been removed), was a 28-year-old Caucasian
female who self-referred to a rural university psychology clinic for treatment due to concern
regarding her ability to manage her thoughts and behaviors concerning eating. Victoria was short
in stature, dressed conservatively, and spoke somewhat timidly of her problems. She admitted to
having experienced several quite severe episodes of AN in the past. She said that while she now
knew what was required to eat healthily, she was again finding eating extremely difficult and
feared another relapse was imminent. She was particularly concerned that her difficulties in eating made it hard for her to concentrate on her work, where, as a child care worker, she had children in her care who were dependent on her. Victoria also reported experiencing a high degree of
work stress, having employment with a number of child care organizations, while also pursuing
her studies for a masters degree in social work. She lived with her partner, who worked in
accounting.

3 Presenting Complaints
Victoria directly connected her current difficulties with eating with a series of distressing events
at work, in which she had been publicly criticized by her employers. I fall out of the routine of
eating when I get distressedwhen life feels out of control. At such times, eating became physically difficult: My stomach doesnt feel hungry and if I try to eat, I feel nauseous. Just the texture of some foods becomes impossible to stomach. Meanwhile, her internal eating disorder
voice would question her need for food: My thoughts are that I dont need this, that my work
should take priority and I can eat later. Despite recognizing that eating regularly was essential
to maintain concentration at work, Victoria reported that she had started to skip meals, which she
recognized as a particularly dangerous sign for her relapsing.
Victorias body mass index (BMI; weight in kg / [height in meters]2) on presentation was
calculated as falling between 21.5 and 22.5, confirming she was in the healthy weight category
(BMI between 20 and 25). Victoria was acutely conscious that this weight was well above
anorexic levels, which by general consensus are taken as a BMI of below 17.5 (Wilson &
Fairburn, 2007), and was concerned that her condition would not be viewed as serious. She, herself, however, recognized that eating was becoming more and more effortful, and was weary of
the extent to which thoughts about eating dominated her attention and intruded on her work and
social life: I feel shut off from whats going on; my head is full of worries about food.

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At the same time, Victoria admitted to being fearful of what life would be like without her
eating disorder. She spoke of the loss of her eating disorder as leaving a void that she doubted
her ability to fill. In particular, she was afraid of being unable to cope with distress without her
eating disorder being there to comfort her and restore her sense of control.

4 History
Victoria reported having been born with hydrocephalus: a build up of cerebrospinal fluid (CSF)
inside the brain that leads to brain swelling. She subsequently had a shunt placed in her brain to
re-route the flow of CSF to the stomach where it can be absorbed. On occasion, further surgeries
are required to unblock or replace the shunt.
Hydrocephalus is commonly associated with intellectual, physical and neurological difficulties (NINDS, 2008). The advice given to Victorias parents by the treating healthcare professionals is unknown, but Victorias perception was that her parents had always assumed her to be
permanently incapable of looking after herself. Her experience was that, despite all her achievements, her parents still viewed and treated her as a retard. She reported that, as a child she was
taught to expect little for myself and encouraged to aim lower. She felt that her parents were
constantly trying to undermine her achievements and her abilities. As such, she came to learn to
keep a low profile, as being noticed only produced painful criticism. Further, Victoria came to
believe that she was less deserving than other people, a feeling that she still found great difficulty combating.
Victoria reported that her problems with eating became apparent between 16 and 17 years of
age. She reported that she had been losing weight gradually when major surgery to replace her
shunt resulted in a further loss of 5kg in 5 days. She continued to lose weight until the cessation
of menses and her losing consciousness after a blood test brought her eating problems to the
attention of her general practitioner (GP). Her weight was then 34kg (her height is 152.5cm,
meaning her BMI was approximately 14.5).
Despite her weight loss, Victoria said she did not regard herself as having AN, because she
was not concerned about her body image. I felt I knew what anorexia was and it didnt fit me.
However, she reported becoming fascinated with the feeling of her bones and the angles of her
body. She found comfort in the idea of taking up less space, which not only equated with being
less likely to be noticed but also with her perception of herself as being less deserving. In addition, eating was one of the few areas in which Victoria was permitted a degree of autonomy. Not
eating was a rare opportunity to exercise control and prove her self-efficacy.
Following the initial diagnosis of AN, Victoria reported she was referred to a nutritionist and
for a period she became equally obsessive about eating healthily. Once she had moved into college
when starting to attend university (at age 17), she admitted that she again cut back on her eating
with the result that she collapsed at an intercollege swimming carnival. She reported that on that
occasion, her friends facilitated her recovery by closely monitoring her eating. Victoria further
reported that, since that time, her weight had dropped alarmingly on a number of occasions.
Usually she had managed to redress this problem by reminding herself of the importance of regular and healthy achievements to maintaining concentration on study and work. However, on occasions, she admitted she had relied on the encouragement and support of friends to ensure she ate
healthily. She ascribed the most recent onset to stress connected with her work in child care.

5 Assessment
The EDI-3 (Garner, 2004) was used as an adjunct to the information gained at the assessment
clinical interview. Results are detailed in Table 1. Victorias score on the primary Eating Disorder
Risk Scale incorporating Drive for Thinness, Bulimia, and Body Dissatisfaction subscales was in

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Table 1. EDI-3 Profiles at Commencement and After 10 Treatment Sessions.
Commencement
Measure

After 10 sessions

t score

Percentile

t score

Percentile

45
35
39
36

21
2
18
11

39
38
34
33

17
13
9
7

43
36
45
36
39
36
38
56
68
64

25
8
31
8
14
6
8
72
96
90

35
37
39
38
39
40
37
63
42
52

8
11
14
10
14
15
5
89
23
61

Eating Disorder Risk Scales

Drive for Thinness
Bulimia
Body Dissatisfaction
Composite
Psychological Scales
Low Self-Esteem
Personal Alienation
Interpersonal Insecurity
Interpersonal Alienation
Interoceptive Deficits
Emotional Dysregulation
Maturity Fears
Perfectionism
Asceticism
Overcontrol Composite

Note: EDI-3 = Eating Disorder Inventory3. Percentile scores relate to International norms for women with eating
disorders not otherwise specified (EDNOS).

the low clinical range, placing her at the 11th percentile against international norms for women
with EDNOS. Scores in this range can indicate an atypical eating disorder which is not driven
by cultural ideals of body shape (Garner, 2004, p. 54). In Victorias case, her low score on the
Drive for Thinness subscale (21st percentile) was also viewed as confirmation that her eating
disorder had not yet resumed control of her thoughts and actions.
However, the EDI-3 also produces scores on five psychological composite scales strongly
related to eating disorders. Victorias score on the Overcontrol composite was in the elevated
clinical range, placing her at the 90th percentile of the EDNOS sample. The Overcontrol composite consists of items evaluating Perfectionism (72nd percentile) and Asceticism (96th percentile).
Asceticism involves spiritual ideals such as self-sacrifice, self-denial, and self-restraint, whereby
thinness is associated with virtue, and restricting food intake represents penance and purification (Garner, 2004). Victorias scores on all other psychological composites were relatively low,
the most elevated being Interpersonal Insecurity (31-st percentile) and Low Self-Esteem
(25th percentile: see Table 1).

6 Case Conceptualization
Victorias case was particularly interesting in that her desire for thinness was not related to cultural ideals concerning the female body. Rather it derived from her parents invalidating behavior
and messages in childhood, which had led her to equate being noticed with criticism and pain,
and instilled an engrained sense of being less deserving than others.
Victorias difficulty in overcoming this idea that she was less deserving occurred in sharp
contrast to her rejection of her parents beliefs and values in other areas. She spoke of them with
quite a degree of resentment and contempt, describing them as sad, unhappy people who lean on
me for emotional support while trying to undermine everything Ive got. In particular, Victoria
was driven by a strong determination to prove to herself that her parents were wrong in their

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dismissal of her abilities: Ive always pushed myself to be the best because no one expected it
of me. Victorias difficulties were conceptualized as emanating from the conflict inherent in the
demand for achievements that demonstrated she could overcome her disability, while fearing
to be noticed or thought to be valuing herself too highly.
Evidence for this conceptualization was provided by Victorias chosen career as a carer, which
enabled achievements to be portrayed as directed toward the service of others. Also revealing was
a conversation during treatment in which Victorias desire to be the best she could be was explicitly
paired with the desire to be invisible. Victoria said she liked to think of herself as a stagehand, making things work behind the scenes: praise makes me feel out of place: its really uncomfortable.
This conflict provided extremely fertile ground for the development of an eating disorder. As
detailed above, loss of weight provided considerable comfort to Victoria, as being thinner was
not only equated with being less likely to attract attention but also with occupying less space,
which had come to symbolize her acceptance of deserving less.
In addition, Victoria revealed that both her parents were considerably overweight and that she
found it hard not to regard such lack of self-control with a degree of disgust, as expressed in the
following extract from a poem, shared with us during therapy:
Tear the flesh, drain the blood
The heart,
Everything that needs too much,
Its all a stupid game
Of greed
And want.

Restricting eating was an area in which Victoria could escape her parents control and express
her autonomy in achieving something which they could not: exposing their double standards and
demonstrating that in this area at least she could claim superiority. To Victorias frustration, her
parents failed to recognize this as a conscious effort: They refuse to accept I have an eating
disorder, they just think I forget to eat.
When things were going well, Victoria could accept the importance of eating regularly to
maintaining the concentration and focus necessary to look after the children in her care. However,
her desire to rise above her disability left her acutely sensitive to any form of criticism. When
things went wrong, her eating disorder voice was quick to chide her for getting above herself.
He sees all the bad in any situation. Anything less than perfection he tells me is weakness.
Moreover, the tone of such criticism could be vicious, as revealed in another of Victorias poems:
Today you tore
Me apart;
Your nails, the sharpness
Of your voice; Your anger,
Hatred of who
I am.

At these times, Victoria craved the security that feelings of hunger brought her. The voice
would also insist that her work had to take precedence over eating and that she neither needed nor
deserved food. Figure 1 shows another extract from Victorias poems, which expresses how
essential hunger and her eating disorders presence had become to her coping mechanisms. The
case formulation of Victorias eating disorder is detailed in Figure 2.
Victorias body weight meant that she no longer qualified for an AN diagnosis. In addition, the
extent to which Victoria satisfied the third AN criteria was questionable. She evidenced no disturbance in perception of body shape and did not deny the seriousness of a low body weight.
Moreover, thinness and abstention did not so much enhance her perceptions of self-worth, but

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I miss your embraceI crave it;

The emptiness, the hunger
Mist around the edges, blurring
The pain - what I feel I deserve.
Your abuse is my
Everything
I need your hate
It has become a part
Of me

Figure 1. Extract from poem expressing the centrality of hunger and A-Rexs presence to
Victorias coping processes.

rather lessened her fears of being noticed and criticized. However, Victorias difficulties in maintaining healthy eating behaviors, the constant intrusion of thoughts about eating, and her fear of
what life might be like without her eating disorder to self-medicate stress, all supported an
EDNOS diagnosis (APA, 2000).

Treatment Plan
CBT-E and narrative therapy were considered as options for treating Victoria. CBT-E was the
more evidence-based therapy and Victorias previous success in overcoming past episodes of AN
had effectively employed a CBT-style approach. On the negative side, however, Victoria continued to relapse at times of stress and CBT-E risked further reinforcing her rigidly controlled
approach to eating. In contrast, narrative therapy possessed persuasive informal evidence.
Dr. Patterson-Kane, as one of the clinical supervisors, had trained with Michael White and David
Epston in the application of narrative therapy in the treatment of eating disorders. She suggested
that the presence of such a strong narrative component in the case conceptualization might make
Victoria particularly receptive to this approach. Moreover, the clients situation was not urgent
(her BMI, as noted above, was within the healthy range). The merits of both approaches were
discussed with Victoria and she opted to try narrative therapy.
The key objectives of this approach were externalization of the eating disorder, deconstructing
the dominant narrative on which the eating disorders hold on the client was based, identifying
occasions (unique outcomes) when Victoria had been able to escape the influence of that narrative, and the development and enrichment of an alternative narrative that nurtured anti-eating
disorder values and behaviors (A. Morgan, 2000). The following sections explain the approach
taken in more detail.

7 Course of Treatment and Assessment of Progress

Summary of Sessions
After the initial assessment session, a total of 10 (1 hr) treatment sessions were conducted lasting
12 weeks in total. The initial 2 sessions concentrated on externalizing the eating disorder. Maisel
et al. (2004) argued that externalization is particularly essential in the treatment of eating disorders because of their capacity to subjugate the sufferers original personality under

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Figure 2. Case formulation of Victorias eating disorder.

an all-pervading belief in their lack of self-worth. Externalization allowed Victoria to distance

herself from A-Rex and thereby examine the tactics he employed to gain her compliance with
his demands (A. Morgan, 2000). Perhaps even more importantly, externalization gave Victoria
the space to explore and articulate to herself what she valued in her life and what A-Rexs influence was denying her (Maisel et al., 2004).
The following three sessions focused on further exploring A-Rexs persona, adopting the
investigative reporter stance recommended by White (2007) to expose his character and values.
This process enabled a comparison with Victorias own values, in particular, the qualities and
behaviors she possessed as a child care worker. These sessions also commenced a process of
deconstruction (A. Morgan, 2000), helping Victoria gain awareness of the beliefs that were
assisting A-Rexs hold on her, and identifying their genesis in those teachings of her parents,
which, in other contexts, she strongly rejected.
The remaining sessions not only continued to reinforce these themes but also began to work
on the development of an alternate story (A. Morgan, 2000), aimed at rebuilding Victorias sense
of self. The emphasis of this alternate narrative was deliberately extended beyond the eating
disorder so as to avoid being directly confrontational (White, 2011). In particular, we sought to
address Victorias deeply engrained fears of being noticed. The search for unique outcomes
(A. Morgan, 2000, p. 52) therefore focused on realms in the clients life where she felt able to
express herself and was not afraid to be seen. These included poetry, dance, and soccer.
Exploration of her feelings, in particular her sense of being present and fully alive in these

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When you are gone
I will cease to
Be as I am. Who
Will I be without
Your aching obsession.
Will my voice be stronger?
The steps of my dance surer
As I follow my path?
Will I laugh
And eat cake with my tea
Drinking in the company of friends?
Can I feel sureness?
Clarity?
Will my heart leave this cage
Allowing me to give myself wholly to others
Who are not you?
Will my garden grow
As I water it (and my leaping dog) each day?
Will there be a cheer as my kick
Sails true, the ball caught by the net at soccer?
Will my voice grow stronger in song
As hunger becomes just a memory,
Not a need
To purge this hate
Within me?

Figure 3. Poem addressing Victorias future emergence following A-Rexs departure.

activities formed the basis of scaffolding conversations (White, 2007, p. 265), which allowed
Victoria to name her alternate story as escaping from the cell her eating disorder had imprisoned
her in. Living for and being present in the moment, together with acting spontaneously and
being willing to take risks, cited by Maisel et al. (2004) as examples of possible anti-eating disorder lifestyles, were identified with Victoria as key to this escape. Victoria was then encouraged to extend these approaches into other areas of her life, including eating.

Progress in Therapy
By the third treatment session, Victoria had become adept at externalizing her eating disorder and
distinguishing the thoughts and values of A-Rex from her own. Initially her comments about
A-Rexs behavior were spoken quietly and submissively, as if she feared upsetting him. She
described A-Rex as large, strong, and aggressive (not unlike a huge dinosaur), whereas she saw
herself, by contrast, as a small mouse-like animal, easily dominated. Reflecting on this difference
allowed Victoria to realize that she would not be able to outfight A-Rex but rather had to use her

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Clinical Case Studies 12(4)

intellect to outwit him. This realization was empowering: her voice gradually became firmer and
more audible and she spoke more critically about his tactics and values. She began to recognize him
as a parasite, who was like the Wizard of Oz in hiding his true nature behind a powerful faade.
In addition, scaffolding conversations that contrasted A-Rexs treatment of her with the standards she set herself as a carer allowed Victoria to challenge the part of her dominant story that
insisted she was less entitled: Caring for others should take precedence over caring for myself.
By the sixth session, this was replaced by I want to care for myself just as much as I care for
others and A-Rex cannot stop me!
From the fourth session until the end of treatment, Victoria was encouraged to begin expressing
her values, beliefs, hopes, and fears through creative writing. Initially, she chose to focus purely
on her relationship with A-Rex but in her later poems she began to address her own emergence
once her eating disorder was gone. This was a particularly important step in allowing Victoria
to challenge her fear that without A-Rex she would be left with an empty void. Figure 3 provides
an example of such a poem. Note the reference to leaving the cage, which came to form the basis
of the alternate narrative and also the repeated reference to her voice being/growing stronger.
Toward the end of treatment, Victoria also began to express herself more in other areas of her
life, particularly the workplace. She became more assertive in resisting unreasonable demands
and in taking initiatives. Initially, this caused some difficulty (see Complicating Factors section) but Victoria persisted and in the final session reported that she had been working particularly successfully with a rather timid child in her care, using a shared approach to risk-taking to
their mutual benefit. Most important, Victoria was beginning to sense a future where she could
relax with friends and just be herself, free of A-Rexs nagging voice concerning food and of his
persistent warnings of criticism and pain. To her surprise, she was discovering that not only did
she have a voice but also that that voice was capable of standing up for itself. In her online journal
(also shared with us), Victoria spoke of realizing that appetite is about more than food. Im finding that Im hungry for life.
Throughout the period of treatment, Victoria continued to struggle with her eating, finding the
maintenance of healthy portions particularly challenging. However, she reported that she was no
longer missing meals. Moreover, there was no significant weight loss, and toward the end of
therapy, she began to report occasionally eating indulgent foods that would previously not have
been entertained.
Following the 10th session, Victoria once again completed the EDI-3. These results can also
be found in Table 1. Most important, Victorias score on the Overcontrol composite went from
the elevated clinical to the typical clinical range (from the 90th to the 61st percentile of the
International EDNOS sample). This was entirely due to a change on the Asceticism subscale,
moving Victoria from the elevated clinical to the low clinical range (from the 96th to the 23rd
percentile), demonstrating how well therapy had succeeded in challenging some of the engrained
childhood beliefs that led to the development of her eating disorder. This was reinforced by
Victorias assertion in the final session that she felt she was beginning to absorb the lessons of
therapy and particularly learning to treat myself the way I would treat others.
However, Victorias score on the Perfectionism subscale remained in the elevated clinical
range, indicating that Victorias expectations and demands of herself remain highly psychopathological. Such beliefs constitute fertile ground to sustain disordered eating behavior (Garner,
2004) and indicate that further therapy is needed to help Victoria develop greater acceptance of
her own self-worth, while continuing to encourage a more spontaneous approach to eating and
life in general.

8 Complicating Factors
The main complicating factor was Victorias heavy workload and the associated stress. She
reported that her manager at her primary workplace was insensitive and unreasonable in the

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demands he made of his staff (particularly in relation to hours worked). He also responded critically to initiatives made without his prior approval, jeopardizing Victorias efforts to incorporate
more spontaneity/risk-taking to her workplace behavior. In addition, Victoria reported that her
partner, who had been diagnosed with depression, was also highly stressed concerning his work,
and hence often not as supportive as he might be. Because of this, and because Victoria seemed
very comfortable with the one-on-one therapeutic relationship that was developing, it was not
judged necessary to involve him in therapy at this stage.
The conditions described provided a fertile environment for Victorias eating disorder to overwhelm her and a pattern quickly became apparent. In session, A-Rex would remain silent;
between sessions Victoria reported that he became more abusive and threatening than ever: seizing on any and every opportunity to criticize her and threatening that when her attempts to defeat
him failed, as they inevitably would, he would make her pay. Victorias fear that A-Rex was
invincible and that her original persona was beyond reach were evident in her poetry:
. . . my soul flaked away
Ashes
They would never rise again
Who I was before
You buried
Long ago.

Despite her best intentions, this made it particularly hard for Victoria to implement changes
out of therapy. However, Victoria was encouraged to view this assault as a sign of her eating
disorders increasing desperation, and a sign of impending success, not failure. In addition,
Victoria was encouraged to try a different method to combat A-Rexs criticism. Rather than trying to shut the voice out, Victoria was encouraged to focus on what A-Rex was saying, but
from the standpoint of a neutral observer (Maisel et al., 2004). She was encouraged to analyze
A-Rexs tactics and consider how she, in the role of Victorias carer, might help counter this
assault. Although Victoria initially found this approach difficult to maintain, it played an important role in the realizations described above concerning A-Rexs true nature and how his influence might be countered.

9 Access and Barriers to Care

Victoria reported the initial decision to seek treatment as having been particularly difficult. She
reported past experiences of counselors having refused to treat her eating disorder symptoms.
Moreover, her eating disorder voice was insistent that not only was she undeserving of therapy
but also that no one would be interested in treating her. Demonstrating belief in her worth and a
commitment to helping her overcome her eating disorder were therefore particularly crucial to
her fully engaging in therapy.
Problems were also experienced initially with Victoria canceling sessions at the last minute.
Her second appointment was canceled on three successive weeks due to additional work commitments. Victorias engrained belief that her value lay in serving others meant such occurrences
constituted a major threat to her therapeutic progress. Victoria also admitted that A-Rex was
repeatedly telling her that the therapist was not remotely interested in her and had much more
important clients to see. Accordingly, the therapist requested that the agreed session be one time

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each week when Victoria would prioritize her own needs above the demands of her workplace,
while also stressing his interest and commitment to her recovery. From this point on, Victoria
attended all scheduled sessions. Although this agreement carried some risk of the therapist setting himself up as another domineering authority in her life, the approach was made in such a
manner as to minimize this risk, and judged necessary lest Victorias resolve to address her eating
problems diminish before any progress could be made.

10 Follow-Up
Victoria is keen to continue with her treatment and, as the provisional psychologist has completed his placement, will continue to be seen by one of the supervising clinical psychologists
(L.P.-K.) when the clinic reopens. Future treatment needs to continue to nurture Victorias emerging sense of self and willingness to express herself. There may also be value in teaching Victoria
improved self-assertiveness skills and in helping her generate more adaptive thoughts to deal
with her anxiety and others negative responses to her initiatives.
In addition, there is scope for the development of a new theme or chapter within the development of Victorias alternate story, focusing on her growing recognition that while A-Rex cannot
be outfought, he can be outwitted. This will include finding examples in her past of times when
she has succeeded in thwarting A-Rexs designs and also assisting her to develop strategies to
deal with those situations that A-Rex seeks to exploit. The goal here will not just be to improve
her eating behavior but also to make her outwitting A-Rex the dominant story in her consciousness, replacing the current narrative of his ability to overpower her.

11 Treatment Implications of the Case

Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy, et al. (2008) note the importance of first
restoring the patient to a healthy weight (and in so doing relieving the affects of starvation on the
patients cognitive capacity) before attempting to address the underlying issues sustaining eating
disorders. This applies as much to the techniques of CBT-E as it does narrative therapy. A key
issue in eating disorder treatment, however, is the high rate of relapse (Berkman et al., 2007), and
the continued hold of eating disorder thinking on sufferers, who like Victoria, have developed a
clear picture of what constitutes healthy eating but are unable to sustain it. This case highlights
the potential value of narrative therapy in preventing such relapse, through the development of
alternative stories that change the individuals beliefs about their self-worth and help them reengage with their non-eating disorder values (Maisel et al., 2004).
The case particularly highlights the importance of externalizing the eating disorder in this
process. In this instance, separating Victoria from her eating disorder was crucial, not only in
allowing her to recognize the conflict in values and character between the eating disorder and her
own deeply held beliefs, but more fundamentally in recognizing and giving voice to the personality that her eating disorder was holding captive (Maisel et al., 2004).
The case also demonstrates the importance of utilizing clinical interviews and psychological
measures to obtain a comprehensive case formulation (Fairburn, Cooper, Shafran, Bohn, Hawker,
Murphy, et al., 2008) of the factors sustaining the clients eating disorder. This is particularly
crucial with clients such as Victoria, whose eating disorders are atypical and not connected with
prevailing cultural ideals regarding the female body (Garner, 2004). In particular, it is important
to look at the broader context of the current beliefs or narrative that is sustaining problem behaviors (A. Morgan, 2000). In this instance, it was recognizing Victorias belief that being noticed
brought pain that proved crucial in identifying the unique outcomes that formed the basis of
alternative story development.

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Victorias case also highlights the potential value of creative writing in reaching and liberating
the personality that has been subjugated by the eating disorder. Inevitably, initial offerings can be
expected to focus on the relationship with the eating disorder itself, which can be helpful in exposing the clients fears and the eating disorders tactics. However, encouraging the client to progress
beyond this stage is important in allowing them to reconnect with the hopes and dreams they once
held. In Victorias case, her fear of the void that would follow her eating disorders departure was
gradually replaced by a new hunger for the vision of liberation she had generated.
Finally, there is considerable value in describing alternative treatment options to clients and
exploring their preferences, based on past treatment experiences and their current relationship
with/feelings about their disorder. In Victorias case, not only did this enhance her buy-in and
commitment to the treatment approach but it also sent an important message regarding her selfworth and status as an expert in her own life. As such, it was, in itself, a first step in rebuilding
her sense of personal agency (White, 2007).

12 Recommendations to Clinicians and Students

When using narrative therapy to treat eating disorders, the clinician should be prepared for the
eating disorder initially increasing the clients level of distress before it starts to get better.
Clinicians also need to forewarn clients regarding this so they do not feel that the treatment is not
working and drop out of therapy. Ideally, this means that initial sessions should be closely spaced
(at least weekly) so that progress can be maintained and monitored. In addition, this reaction can
be used positively in serving to demonstrate the eating disorders values and bullying nature,
and by projecting this reaction as a sign of its concern about loss of control. As treatment progresses, the encouragement of self-expression in the client also has to be handled with care:
Taking risks and self-assertion are crucial building blocks in developing the alternate story, but
the skills needed to do this successfully are often underdeveloped in clients with eating disorders.
A slow, nurturing approach is therefore required when treating clients with EDNOS using narrative therapy, which while still encouraging spontaneity, focuses on smaller steps, in less challenging environments.
The narrative therapist should also not be afraid to move away from the territory of eating
during the development of the alternate story. Naturally, care has to be taken that the clients eating behaviors do not lead to further health deterioration during this phase. However, removing
the focus from eating makes it less challenging for the client to explore and reconnect with the
things they value. Removing the focus from eating also allows for a fuller exploration of the
issues that have led to the development of the eating disorder.
Acknowledgments
The authors would like to thank the client for her efforts in the therapeutic process. The authors would also
like to thank the fellow provisional psychologists and staff at the UNE Psychology Clinic for their assistance with this case study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies

Ned Scott is a Provisional Psychologist currently completing the final year of his clinical masters degree
at the University of New England (UNE). He has a particular interest in the treatment of eating disorders.
Tanya L. Hanstock, Associate Professor, is a Senior Clinical Psychologist and the Director of the UNE
Clinical Psychology Program. Her main area of clinical experience and interest includes mental health
disorders.
Lisa Patterson-Kane is a Clinical Psychologist, Senior Lecturer, and is the Clinic Coordinator of the UNE
Psychology Clinic. She has a strong clinical and research interest in rural and remote mental health. She also
has a strong interest in the application of narrative therapy to meet client needs when working within rural
and remote areas.

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