‘Anorexic’ Adolescents: Negative and Positive Resistances in Narrative Therapy¹

1. The focus of this article is on alternative (i.e., poststructuralist) understandings of anorexia and narrative-based practices of therapy for adolescents. It does not address any forms of medical attention. In addition, pharmacological treatments are not covered, as the evidence base for the use of drugs for anorexia is poor (Mayo Clinic, 2017; Morris & Twaddle, 2007). The article is proposed for those anorexic adolescents who consent to undergoing treatment, specifically with a narrative therapeutic approach. It is acknowledged that a number of anorexic adolescents may not agree to treatment at all. Disincentives to treatment could be (a) the adolescent thinking that he or she does not need treatment; (b) fearing weight gain, such fear being based on current known modernist treatment approaches of imposed feeding/eating/weight gaining strategies; or (c) not considering anorexia a situation requiring psychotherapy, but rather a lifestyle choice.

Abstract

This article draws on notions of negative and positive resistances in exploring alternative understandings of ‘anorexia’, in a narrative therapy based approach for ‘anorexic’ adolescents. In doing so, it posits ‘anorexic’ lifestyles as forms of coping mechanisms against dominant social discourses. Narrative treatment is to facilitate a movement away from subjection of dominant social discourses, and should enable intentional movements towards ethical subjectivities. This means that adolescents should then find no need to embrace ‘coping’ mechanisms that lead to lifestyles of ‘anorexia’, and treatment can shift away from food, weight, and body image, to dealing with ‘problems in living’.

Notes

1. The focus of this article is on alternative (i.e., poststructuralist) understandings of anorexia and narrative-based practices of therapy for adolescents. It does not address any forms of medical attention. In addition, pharmacological treatments are not covered, as the evidence base for the use of drugs for anorexia is poor (Mayo Clinic, 2017; Morris & Twaddle, 2007). The article is proposed for those anorexic adolescents who consent to undergoing treatment, specifically with a narrative therapeutic approach. It is acknowledged that a number of anorexic adolescents may not agree to treatment at all. Disincentives to treatment could be (a) the adolescent thinking that he or she does not need treatment; (b) fearing weight gain, such fear being based on current known modernist treatment approaches of imposed feeding/eating/weight gaining strategies; or (c) not considering anorexia a situation requiring psychotherapy, but rather a lifestyle choice.

2. The late Michael Guilfoyle was an academic and a practicing narrative therapist. His book (2014) is about both theory and practice that addressed the question: What sort of world does the person in narrative therapy occupy, and what impact does that have on him or her? He discussed the curious and creative tension between what has been described as the constituted subject, on one hand, and the free, ethical subject, on the other. In other words, on the one hand, there is the Foucauldian poststructuralist articulation of the person constructed by social forces—a person as “the product of power” (Foucault, 1983, p. xiv) that shapes a person in narrative therapists’ sense as being constituted in stories (White, 1993). On the other hand, Guilfoyle (2014) submitted that the notion of personal agency has always been an essential part of a narrative therapy's view of the person (p. 5).

3. Discourses in this article can be contextualized as being social and cultural practices that support certain ways of thinking and behaving, which are then internalized by an adolescent. In other words, discourses are social norms and ideas that prescribe how an adolescent should think and act, which are dominantly available to an adolescent who then feels it necessary, for various reasons, to embrace in order to make sense of her or his life.

4. An expression such as, “an adolescent in relationship with ‘anorexia,’” in narrative therapy reflects the use of (externalizing) conversations in which the problem (i.e., anorexia) becomes the problem, and is a counterpractice to those conversations that objectify the identity of an adolescent as an anorexic. That means that anorexia becomes an entity that is separate from an adolescent, and the expression releases adolescents from being tied to “restricting ‘truths’ about their identity and negative ‘certainties’ about their lives” (White, 2007, p. 26). This separation of the life of an adolescent's identity from the identity of anorexia provides the potential for “new options for taking action to address the predicaments of their lives” (White, 2007, p. 26).

5. A “structuralist” subject has fixed and essential identities that are found within the inner-self. His or her ideas, problems and qualities are linked to some internal inner-self, and these “deep structures” and “essential truths” are objective. They shape life, and are always consistent.

6. Briefly, DSM–5 symptoms for a diagnosis of anorexia are (a) significantly low body weight; (b) intense fear of gaining weight or becoming fat; and (c) disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight

7. More recently, innovative integrations of a number of models of family therapy have been used, mainly for adolescents (e.g., Espie & Eisler, 2015; Gowers et al., 2007; Le Grange, Lock, Loeb, & Nichols, 2010; Watson & Bulik, 2013), and have provided some evidence to suggest that forms of family-oriented therapy may be effective in certain circumstances (Couturier, Isserlin, & Lock, 2010; Fisher, Hetrick, & Rushford, 2010; Godart et al., 2012; Jewell, Blessitt, Stewart, Simic, & Eisler, 2016; Lock et al., 2010).

8. Narrative ways and ideas provide a respectful and empowering approach to therapy. They stimulate a person's sense of individual agency, sense of direction, and an intentional state of self-constructed identity that is consistent with and emphasizes the personal values, beliefs, hopes, and dreams they stand for in life (e.g., Carey & Russell, 2003; Dawson, Rhodes, & Touyz, 2014). For substantive understandings and details of narrative therapy, see Freedman and Combs (1996), Guilfoyle (2014), Madigan (2011), Monk, Winslade, Crocket, and Epston (1997), White (2004, 2007, 2011), and White and Epston (1990). This article refers to limited practices of narrative therapy—practices that are specific and material to the content and focus of this article. As such, they are not intended to reproduce the map(s) of narrative practice or be “a ‘true’ and ‘correct’ guide to narrative practice, whatever narrative practice is taken to be” (White, 2007, p. 5). Although not specifically discussed in any detail in this article, narrative practices and understandings—such as conversations in regard to unique outcomes, externalizing, naming, and relative influencing questions—remain necessary practices, with understandings discussed in this article that further inform these therapeutic practices.

9. These comments are provided merely as examples of some experiences of adolescents that may lead to some forms of anxiety, stress, conflict, and challenges. They are not meant to provide any form of clinical material for use in a medical model approach. It is also important to emphasize that this article makes no claim that the issues faced by Kirsty and Helen (that is, original unwanted dominant discourses of puberty), which led to their specific coping (resistant) behaviors, are sole sources of stress, anxiety, and conflict that adolescents may have to deal with. Of course, other original sources of stress—such as changing schools, failure at sport, exams, issues with body image—may promote various coping behaviors, which again would be deemed symptoms of anorexia (e.g., Dworkin, Javdani, Verona, & Campbell, 2014). It is submitted that the proposed narrative therapy approaches in this article, applying both negative and positive understandings, would also be appropriate for these persons.

10. In narrative therapy, anorexia is not deemed to be a psychiatric/medical/pathologized concept, but is also not perceived as purely a construction or story. Instead, it is usually understood to be “a real and dangerous product of a variety of social power dynamics and gender prescriptions, the reproduction and extension of which are enabled through the recruitment of individuals who go on to develop difficulties with various eating and body-related practices (e.g., Epston & Maisel, 2009)” (Guilfoyle, 2012, p. 637).

11. Although this article is focused specifically on aspects of narrative therapy in relation to anorexic adolescents, it must be mentioned that, in cases such as Helen's, the situation in regard to physical and sexual abuse would also need to be addressed. It is assumed that in most Western countries there would be guidelines for psychotherapists for informing a third party who acts in an official capacity about suspected incidents of physical and sexual child abuse. For instance, the Australian Psychological Society's guidelines: http://www.psychology.org.au/assets/files/reporting_child_abuse_ethical_guidelines.pdf.