Diane Girardot is sending dispatches from the Renfrew Center Foundation's 22nd Annual Eating Disorder Conference in Philadelphia this weekend.

by Diane R. Girardot

Controversy and Collaboration. Exactly what does that mean?

This year's Renfrew Center Foundation Eating Disorders Conference is giving life to these two words and the sentiency was palpable in Friday's keynote presentation to about 700 attendees.

Three speakers of various mental health backgrounds stood firm in their conceptualizations of a popular treatment technique within the field called "externalization" - where disordered eating is attributed to an evil separate entity existing outside of the client.

The first speaker espoused a definitive pro-entity stance, the second presenter stood as a more cautious and conscientious user of the dissociative concept, the third an unabashed nay-sayer.

But at the end of the two hour confab, the nay-sayer gave externalizing some credence and the believer gave a half nod to the flip side. The moderate smiled. And the collaborative heart of controversy grew three sizes!

What was it that was said?

Conference chair and Renfrew Foundation vice-president Judi Goldstein announced at the beginning of the quasi-debate that controversy is welcome and invited each year because it "moves the field forward and makes us think." Early controversial discussions were often ripe with aggression, criticism, diverse beliefs and strong convictions, she says. Today, with so much to learn, working together has been enlightening and productive.

Externalization may have begun with Sigmund Freud who coined "projection" as a means to cast out uncomfortable anxious feelings, explained middle grounder Dr. Ivan Eisler of Kings College in London. Later, art and storytelling and play therapy became venues for placing stress outside of ourselves on a canvas, in a journal or with battling plastic T-Rexs. The profound human need for interpersonal relationships helped further extend our "selves" in relation to others beyond our own egos. Gestalt crafted the "empty chair" technique to confront the anxiety brought upon us by our tormentors. (How many of you thought of Clint Eastwood?)

Early beliefs about anorexia nervosa blamed parents and the family. Move ahead 45 years and evidence points to it being a brain-based disease. Dr. Eisler said thinking of distressing disordered behaviors as symptoms of a genetically driven disease rather than part of the person or the fault of the mother reduces the stigma and refocuses energy from blaming to refeeding the child.

Amy Baker Dennis, PhD., founding president of Eating Disorders Awareness and Prevention (NEDA), as first speaker, explained the widely-used technique of externalizing serves to separate the person from the disease. The strategy includes going as far as assigning the vile "voice" within with names like Ed, Ana, or Rex. This "Other" overpowers the person and is responsible for the starvation, binging and purging, narcissism, moodiness and ill temper associated with eating disordered diagnoses.

The usual lines from Ed: "Don't eat that, you are fat!" "People lie who say they want to help, they just want to make you fat!"

From a family perspective, externalizing allows a parent to say things to Ed that you can't say to the loved one," Dr. Dennis said, claiming externalizing is a plus for families struggling to understand and manage when an eating disorder invades their home.

Dr. Eisler agreed but encouraged using externalizing more cautiously to avoid an "It wasn't me!" or "The devil made me do it!" excuse. He suggests mapping how Ed, Ana or Rex, actually influence a person's life. Asking how Ed got a person to do a particular thing or how a person successfully stopped Ana from ruining date night, explores other ways to externalize.

Eventually, he said, the goal is to demote externalization and transfer responsibility to the person because, after all, it is a metaphor. It isn't real and never was which is the greatest concern with the technique, warned Kelly Bemis Vitousek, Phd., associate professor of psychology at the University of Hawaii.

A frightful outcome is often that the eating disordered voice becomes a creature that develops agency, ill will, and connives to cause the demise of the actual person, she explained.

"It can be good at some point but there is a potential to get stuck", she pointed out, "in the dichotomy of good and evil, wolf and lamb, black and white."

Dr. Vitousek, however, recognized her own use of externalizing each time she medically explains the effects of starvation on digestion or other external explanations of symptoms in order to reduce patient or family anxiety. She thanked our fence-sitter for helping her soften towards the technique. Dr. Dennis reconsidered her stance by agreeing externalizing could create a lingering threat if given too much power in the therapeutic process.

A post-keynote discussion between strangers at the coffee station postured that instead of demonizing the eating disordered voice, think of it as a friend who shoulders the anxiety until the person can sort it out. Another controversy and collaboration had begun.....