Key-in-session identity negotiations in a first line treatment for adult anorexia nervosa

TL;DR

This study explores how people with anorexia nervosa negotiate their identities during therapy sessions, highlighting the gradual shift from an identity dominated by the disorder to one focused on recovery.

Contribution

The study introduces a novel focus on identity negotiations within therapy sessions for anorexia nervosa, emphasizing the role of identity shifts in treatment outcomes.

Findings

Participants initially exhibited fragmented identities dominated by anorexia nervosa.

Therapy sessions facilitated a gradual process of rebuilding identities and lives outside of anorexia nervosa.

Preferred identities and hopes for recovery emerged more frequently in later therapy sessions.

Abstract

Exploration of client identity negotiations during treatment for Anorexia Nervosa (AN) is a relatively new area of research. Research suggests that difficulties with identity negotiations may present as a barrier to treatment. This study sought to explore individuals’ identity negotiations during therapy sessions using Compulsive Exercise Activity Therapy (LEAP) combined with Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN). Analysis focused on moments in therapy where individuals’ identities were dominated or defined by AN and where alternative identities could be generated.

40 in-session transcripts from sessions at early, mid and end points of the CBT-AN (with LEAP) treatment were qualitatively analysed for nine of the 78 participants in the original randomised control trial. Through a constructivist framework, thematic analysis was used to identify surface and latent meanings and discursive material participants used to negotiate their identities in the context of therapy sessions.

Analysis of in-therapy transcripts generated two themes pertaining to identity negotiations: (1) troubled identities and (2) rebuilding identities and lives outside of AN. Early therapy sessions explored fragmented and AN dominated identities, including how AN was troubling to participants’ sense of self, contributed to conflicted identities, positioned them outside of normality, and was associated with isolated and othering identities. Within therapy sessions, participants engaged in a recursive process of shifting relationships with AN and themselves and building identities and lives outside of the AN identity. This included generating hopes for recovery and the future more frequently in mid- to late- therapy sessions.

Identity negotiations evident in the therapeutic conversations aligned with the key components of the CBT-AN intervention, including addressing (1) the characterisation of oneself as ‘an anorexic’ and (2) the diversification of roles and activities to broaden and enhance self-concepts. Future developments of therapeutic interventions for AN would benefit from greater consideration of ways to assist individuals to more comprehensively address problematic identities, including uncovering identities hidden by the AN identity and generating preferred identities.

Trial Registration: Ethics approval was obtained at the time of the initial study and for this embedded research by the HREC at the Western Sydney University (HR777332).

The online version contains supplementary material available at 10.1186/s40337-024-00979-0.

Current psychological therapies for Anorexia Nervosa (AN) have recently identified that the sense of AN as part of a person’s identity, or who they understand themselves to be, may pose barriers for treatment. In this study, therapy session transcripts from previous research using Compulsive Exercise Activity Therapy (LEAP) combined with Cognitive Behaviour Therapy for AN (CBT-AN) were thematically analysed to explore participants’ experiences of identity shifts in-session. Particular attention was paid to moments in therapy where individuals’ identities were heavily influenced by AN and moments where alternative and preferred identities were generated. Outcomes from this study suggested that the process of participants negotiating their identities outside of AN was a gradual and repeated one throughout treatment, which involved building hopes for recovery and a future less dominated by AN. Findings from this research support the need for future treatments to broaden their scope to more comprehensively explore changes in identity during intervention, particularly in building new identities outside of the AN identity.

The online version contains supplementary material available at 10.1186/s40337-024-00979-0.

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