Narrative therapy for anorexia nervosa: a case study

Introduction

Narrative therapy, developed within the systemic therapy framework, focuses on exploring the individual’s personal story and understanding how difficulties shape their experiences. A central therapeutic process is externalisation, through which the problem is separated from the person, allowing space to identify moments in which the person resisted the problem`s influence. From that point onward, with the therapist acting as a co-author, the individual deconstructs the problem-saturated narrative and constructs alternative, problem-free narratives.

Anorexia nervosa is a severe psychiatric condition characterised by persistent restriction of food intake, significantly low body weight, intense fear of weight gain, and disturbances in the perception of body shape and weight.

From a narrative perspective, the eating disorder is understood as an entity that can dominate the person’s thoughts, behaviours, and relationships. By externalising the disorder, therapy may help the individual strengthen personal agency and develop new meanings around recovery and identity.

Case description

We present the case of Ana, a 16-year-old adolescent first referred in 2021 for self-harm, low mood, irritability, and reduced functioning. She was admitted to the clinic multiple times, with gradual improvement in her symptoms, achieving recovery in the early months of 2022. In March 2023, she re-presented with significant weight loss, caloric restriction, obsessive calorie counting, and low energy. Her history included parental divorce, maternal caregiving, and childhood emotional abuse by her father.

In July 2023, after several months of attempting to manage her difficulties independently, inpatient admission was recommended to allow close monitoring and intensive therapeutic support. At admission, her weight was 44–45 kg, height 1.73 m, body mass index (BMI) 14.7 kg/m² and pulse 44–45 bpm.

Alongside pharmacological treatment for psychiatric comorbidities, narrative therapy techniques focused on externalisation were employed. Ana named the problem “Anorexia” and explored the distinction between her own plans for life and the plans imposed by the illness. As part of the therapeutic process, she wrote a goodbye letter to “Anorexia.”

During admission, Ana demonstrated increasing insight into the impact of the illness on her life and actively engaged in recovery planning. She also accepted visits from friends who brought her home-cooked meals, which she consumed.

At discharge, her pulse had improved to 60 bpm. She developed a relapse prevention plan, accepted her mother’s support, and defined a personal safety weight range of 50–55 kg.

Following discharge, weekly telephone follow-up sessions were maintained to reinforce recovery-oriented behaviours. In November 2023, Ana reached 50 kg, the lower threshold of her agreed safety range, and received a Certificate of Appreciation in recognition of her progress.

Conclusions

This case illustrates the potential value of narrative therapy, particularly externalisation techniques, in the treatment of adolescent Anorexia nervosa. Externalisation may facilitate insight, strengthen personal agency, and support recovery. The therapeutic alliance may represent an important factor in treatment engagement and outcome.

References

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