Narrative Therapy as an innovative approach to Anorexia Nervosa treatment: a literature review

ABSTRACT

Anorexia is an eating disorder characterized by a morbid fear of gaining weight, excessive restriction of food and intense and exaggerated practice of physical exercise. There are two subtypes of anorexia: restrictive and purgative. Its prevalence is mainly in female adolescents aged 15 to 19 and entails multiple harmful physical, psychological, social, and emotional consequences. Anorexia is portrayed as a multifactorial disorder, requiring a biopsychosocial perspective and a multidisciplinary intervention to address all the affected areas of the individual. In this article, we approach the appliance of Narrative Therapy by White and Epston ((1989). Literate Means to Therapeutic Ends. Dulwich Centre Publications), which advocates that the psychotherapeutic treatment can be carried out together – psychologist, client and family – with the literature supporting it. Anorexia is an egosyntonic disorder associated with a high mortality rate. It should be noted that the cure for anorexia is not granted since there is an increased number of relapses and treatment dropouts. For this reason, an innovative approach like narrative therapy can be approached with promising results.

KEYWORDS:

• Eating disorder
• anorexia
• adolescence
• body image
• narrative therapy
• multidisciplinary intervention

1. Introduction

Anorexia is an eating disorder characterized by dysfunctional behaviors related to food that are harmful to physical and mental health, among them the morbid fear of gaining weight, excessive restriction of food and intense and exaggerated practice of physical exercise (Striegel & Rosselli, 2017). Given its impact on people's life, treatment is paramount, and we emphasize the Narrative Therapy (NT) intervention, whose reference authors are Michael Epston and David White (Chimpén-López & Muñoz, 2021). The NT reveals a primordial separation of the individual from the problem, assuming that person is not the problem; the problem is the problem on which great importance is placed in understanding and accepting anorexia, allowing the construction of alternative narratives (White, 2012).

With the main objective of investigating the anorexia eating disorder and its respective functional and psychotherapeutic characteristics, this article is configured as a literature review, composed of a theoretical analysis of the last 20 years of research going through meticulous studies selection described in the Materials and Methods section. To provide more specific analysis, the results of this review were divided into theme sections: Adolescence and Anorexia; Eating Disorders; Contextualization of Anorexia; Predisposing, Precipitating and Maintenance Factors; Quality of Life; and Psychotherapeutic Treatment: Narrative Therapy.

2. Materials and methods

A systematic search of the existing literature was carried out using three digital databases: Google Scholar, Scielo and PubMed. The search focused on studies published in English or Portuguese using narrative therapy in anorexia treatment, from 2002 to 2022, in peer-reviewed journals. All types of articles (not reviews and editorials) were included if they involved individuals of any age with anorexia undergoing Narrative Therapy. The search used seven keywords: anorexia, adolescence, risk factors, quality of life, treatment, psychotherapy, and narrative Therapy.

The studies were then selected according to specific inclusion criteria: those in the defined time frame (last 20 years) and those that contained the keywords in the title and/or abstract. Studies about other eating disorders were excluded. Therefore, a total of 48 documents were selected, whose key conclusions are exposed next.

3. Results

3.1. Adolescence and anorexia

According to Araújo (2012), the ability to transform the appearance through what one yearns for is the main explanation of anorexia. The balance between what we are and want to be is lost, creating a dysfunction. This desynchronization is a characteristic of the adolescence stage. It is a period of atypical and unique growth in which individuals overcome biopsychosocial changes fundamental to developing their autonomy and respective identity (Fabrin et al., 2013). According to Papalia and Feldman (2013), adolescence is a transitional phase that causes physical, cognitive, emotional, and social changes, varying from context to context, that is, the family, social and cultural environment in which the individual is living his/her significant role. Adolescence is expected to be an emotionally, socially, and psychologically challenging period, and despite being also a period of discovery, it is also a period of vulnerability (Fabrin et al., 2013).

The change in this developmental stage generates instability and insecurity (Araújo, 2012), especially in the current times and in the female gender, since following social and aesthetic standards proves to be more important for adolescents in favor of their own mental and physical health. Therefore, given the body changes faced in this period and the need to be accepted by peers and belong to a particular group, adolescence is the riskiest stage for developing eating disorders (Fleitlich et al., 2000 cit. in Araújo, 2012).

3.2. Eating disorders

Eating disorders are related to dysfunctional behaviors linked to food, causing severe consequences for physical, social, emotional, and psychological health, influencing individuals’ well-being and quality of life (APA, 2014) and having high mortality rates (Striegel & Rosselli, 2017). The literature indicates that these disorders usually appear from 12 to 25 years old (Striegel & Rosselli, 2017).

According to Leonidas and Santos (2015), eating disorders are accompanied by various symptoms: physical, emotional, and psychic (which will be discussed in section “X”). The frequency of symptoms can indicate the presence of the following disorders: anorexia, bulimia, binge eating and restrictive eating disorders (APA, 2014). Mohammadi and colleagues (2020) suggest some comorbidities associated with these disorders. The main one is obsessive-compulsive, followed by major depression, social phobia, generalized anxiety disorder and, with a lower percentage, attention deficit disorder and hyperactivity.

Body image and corresponding dissatisfaction are contextualized as present in the development of eating disorders, becoming the target of health professionals in several studies (Broering & Scherer, 2022). Fabrin et al. (2013) define “body image” as a dynamic psychological construction that highlights the internal perception everyone maintains about their body – size, shape, and appearance – equally, it concerns feelings, attitudes, emotions, beliefs, and experiences arising from this perception.

The negative body image can lead the adolescent to social comparison and self-objectification, the tendency to downgrade her/himself in comparison to society standards and compare her/himself to an established cultural ideal (Burychka et al., 2021). These authors complement this idea by mentioning that when the first unhealthy diet occurs and when weight control behaviors occur consistently, they are signs that might be associated with more severe eating disorders like anorexia.

3.3. Anorexia nervosa

3.3.1. Contextualization

The word anorexia originates from the Greek – anorexis – “an” means “without” and “orexis” is “desire for”. The junction of these two Greek words means “reduced appetite.” The literature presents the disorder as “Anorexia Nervosa” (AN), in which the word “nervosa” refers to the psychological nature of the disorder (Almeida et al., 2018). According to the authors, AN originated in the Middle Ages, and during the 17th-19th centuries, it was related only to the female public, described as hysterical anorexia, hysterical and nervous compulsion.

Currently, AN maintains a significant association with the female gender, mainly in adolescents (15 to 19 years old) and adult women (although it does not frequently occur after 40 years old; Leite & Amaral, 2015). The motivation and the main objective in their lives are weight loss, obeying (often), to obsessive thoughts (Gailledrat et al., 2016). According to Gailledrat et al. (2016), this disorder is classified as the third most common chronic disease in female adolescents. Death may often occur due to various complications of the clinical condition and suicide.

Dias (2017) suggests that AN is typical of cultures with abundant food, and diet and weight loss have social relevance. According to Dias (2017), although AN is more common in developed and western countries, eastern countries and ethnic minorities are not immune. Food is fundamental for human survival. However, from the perspective of AN, food is something irrelevant and unnecessary for the body (Leite & Amaral, 2015). Body dissatisfaction originates in individuals with AN, the perception of a fat body that does not exist, making them feel obese and too thin. Nevertheless, they need help understanding the gravity of this situation due to their distorted perception of their appearance. In addition to these characteristics, other signs are regularly present in individuals with AN, such as extreme anxiety, excessive perfectionism, and the inability to feel fulfilled (Leite & Amaral, 2015), thus explaining the comorbidity with other eating disorders.

Individuals with AN assume weight loss by reducing food intake, performing intense physical activity, self-induced vomiting, and using laxatives or diuretics (compensatory and purgative behaviors; Almeida et al., 2018). The authors argue that their search for perfection is only found in thinness; hence they develop a morbid fear of gaining weight and adopt behaviors to make it impossible. All these characteristics meet the diagnostic criteria defined by the DSM-V (APA, 2014): (a) restriction of food intake (even if you need to) concerning age, gender, period of development and physical structure; (b) intense fear of gaining weight and producing behaviors that prevent weight gain; (c) disturbance in the way the individual perceives his own body, making incorrect self-assessments and, on the other hand, not recognizing the severity of his/her current low weight. In numerical terms, the body weight of individuals with AN is around 15% below the norm (Almeida et al., 2018).

According to APA (2014), AN is divided into two subtypes: restrictive – the individual does not present episodes of binge eating (in the last three months), achieving their weight loss through diets, fasting and intense physical exercise; and purgative – unlike the previous one, there are episodes of binge eating and use of laxatives and diuretics, even including self-induced vomiting. Although there is this differentiation between the two subtypes, the diagnosis is not static; individuals can alternate when in the course of the disease. Anorexia disorder is further classified based on clinical symptoms, the degree of functional disability and the need for meal supervision as mild, moderate, severe, and extreme (APA, 2014).

Individuals with the restrictive subtype of AN have specific characteristics, such as obsession, perfectionism, passivity, introversion, and negative self-assessment (Claudino & Zanella, 2005). From another perspective, individuals with the purgative subtype are impulsive, managing to reach higher levels of obsession and perfection (Claudino & Zanella, 2005).

3.3.2. Predisposing, precipitating and maintenance factors

The etiology of AN is multifactorial since several conditions – genetic, social, cultural, environmental, biological, and psychological – are at their origin and maintenance (APA, 2014).

From the perspective of Almeida and colleagues (2018), it is difficult to identify the causes of anorexia disorder accurately. The authors emphasize the pertinence of using the biopsychosocial model to obtain a more comprehensive understanding of how factors interact in the onset and maintenance of the disease.

The predisposing factors are being female, having a family history of eating disorders, having low self-esteem, being a perfectionist and having difficulty controlling emotions (Morgan et al., 2002). The precipitating factors are restrictive diet, loss or separation, changes in the family cycle and unrealistic expectations regarding oneself (Morgan et al., 2002). The authors also refer to the maintenance factors, highlighting the distortion of the body image, cognitive biases, and purgative behaviors. Fairburn and colleagues (2003) identified four mechanisms of AN maintenance: 1) perfectionism, which includes the fear of failure, being constantly attentive to the performance and having negative self-criticism; 2) low self-esteem; 3) mood intolerance with alternate negative and positive states that may lead to substances consumption (laxatives or diuretics), self-induced vomiting and excessive physical exercise; and 4) interpersonal difficulties.

The research by Nunes and colleagues (2017) aligns with what was already mentioned since they point out risk factors: dissatisfaction with one's body, low self-esteem, being female and the family culture.

Studies highlight that parental eating practices, such as restriction and excessive parental control, limit autonomy leading children and adolescents to make negative choices in their food. Parental eating practices and sociocultural influences are critical to the development of AN (Gorwood et al., 2016). According to Claudino and Zanella (2005), the family environment often underlies the origin of AN, particularly the mother, who excessively values the daughter's appearance, confronting her with disproportionate physical activities. Deep down, there is the mother’s projection towards the daughter; that is, the mother idealizes in the daughter something that she once was or wanted to be, expressing high expectations towards herself regarding her future behavior (Claudino & Zanella, 2005). Treasure and Schmidt (2013) argue that overprotection and family discord also maintain the disturbance, given that the adolescent misses (or may not be able to achieve) his autonomy and identity.

According to Broering and Scherer (2022), sociocultural standards stimulate the stereotype of being thin as “beauty” in adolescents, which causes greater body dissatisfaction in those who do not fit (or think that they do not fit) in this representation, generating high levels of malaise and low self-esteem. In this line of thought, social networks and all the constructs involved in them and family and peer experiences are significant in how adolescents evaluate their bodies and aesthetics (Broering & Scherer, 2022). These authors discuss the consequences of social networks, especially for female adolescents, as they try to become like famous people, adopting restrictive and dangerous behaviors for their health. Social networks intensely emphasize thinness through advertisements of products and miraculous diet regimes, perpetuating the idea that beauty is found only in low weight (Broering & Scherer, 2022).

Some risk groups for AN can be identified: female adolescents (due to the greater tendency to follow beauty standards and negative self-assessment), models, dancers, and gymnasts (Dias, 2017), and female professions where thinness is required, a perfect ideal to be achieved. Perfection ideal matches the Barbie doll, a benchmark for beauty worldwide, consisting of a dysfunctional body, reduced breasts, a tiny waist, long legs, and narrow feet (Lima, 2013). Faced with this description, contempt for one's body is an automatic thinking process for insecure adolescents and adult women who do not have these model characteristics. Dislike of their bodies leads to unhealthy behaviors, like AN (Lima, 2013). Especially in the beginning, AN behaviors achieve positive appreciation, with comments from family members and peers, such as “you look prettier and thin.” These comments work like reinforcements to continue food restriction since the objective is to maintain external validation (Broering & Scherer, 2022).

Finally, other factors contributing to the disorder's onset and maintenance are mainly related to the individual's family: a non-integrating, unsafe, violent, and negligent family environment with attachment disorders (Fairburn et al., 2003). The authors add that sexual abuse and bullying in childhood are explanatory frameworks for AN (Fairburn et al., 2003). A study by Leonidas and Santos (2015) also reports bullying and criticisms about weight and food as determinants of developing this disturbance.

3.3.3. Quality of life

Giacomini (2004) refers that the World Health Organization (WHO) conceptualizes “quality of life” considering three aspects: subjectivity – the perception that the individual has of himself; multidimensionality – consideration of physical, social, and psychological factors; and bipolarity – positive and negative aspects. That said, it is possible to verify that AN is a multifactorial disorder, in which the individual does not have an accurate perception of himself, distorting his/her image; therefore, not being aware of the negativity of his/her condition, leading him/her to purgative and compensatory behaviors.

Adolescents with AN cannot understand their feelings and discriminate against reality. Hence, they experience social, emotional, behavioral, and learning difficulties (Araújo, 2012). It is possible to state that the understanding of the self of an individual with AN is disturbed. At the same time, they also appear to have low levels of self-differentiation and confusion with their own emotional and mental states (Treasure & Schmidt, 2013). Cordás and Claudino (2002) state that the morbid fear of gaining weight and the extreme diet over a long period considerably impairs the individual's clinical status. Tirico and colleagues (2010) concluded that individuals with AN experience higher levels of loneliness, low self-esteem, isolation, lack of hope and difficulty establishing love and friendship relationships. Social relationships are rare and damaged, and family relationships decline because individuals with AN exclude themselves from all his/her interests and support networks, increasing isolation. According to the literature, it is common for individuals with anorexia to refuse food they previously enjoyed very much due to calories and to refuse to eat socially with friends and family (Peterson & Fuller, 2019). According to Cardi and colleagues (2017), the social dimension of adolescents with AN is significantly affected, mainly because their capacity for emotional expression and interpretation is impaired, leading to interpersonal difficulties and negative social interpretations. The authors add that these impairments are due to high stress and hunger, which prevent communication and reciprocity with others.

Several psychological consequences affect the individual's quality of life, such as depressed mood, social isolation, irritability, sleep problems and sexual disinterest; however, they can decrease and even normalize after weight gain (Ross et al., 2014). High anxiety, sadness, discouragement, guilt, shaming, and suicide attempts are also identified (Oliveira & Santos, 2012).

As stated by Ross and colleagues (2014), AN is an evident disorder in the physical dimension. Individuals with AN are bodily skeletal due to muscle atrophy and the absence of fat, so they have yellowish, cold, and dehydrated skin (Ross et al., 2014). The hair is likely to fall out, together with the nails, which also become weaker (Ross et al., 2014). The authors point out another symptom in women, amenorrhea (absence of menstruation), after menarche. In pre-adolescents, there is a delay in puberty, deficits in the quality of growth and height below expectations. Another severe consequence of AN is osteoporosis which involves a reduction in bone density (Westmoreland et al., 2016) and is estimated to be present in more than 50% of adolescents with anorexia. Following AN of the purging subtype, in response to vomiting, there may be loss of tooth enamel, dental caries and calluses on the back of the hand, known as Russel's Sign (Ross et al., 2014).

According to Campbell and Peebles (2014), intense physical exercise combined with intense dieting leads to protein deficiencies, impairing several systems of the human body functioning, namely the cardiovascular, renal, gastrointestinal, endocrine and reproductive systems. Additionally, it also influences neuropsychological functioning through the reduction of brain tissue (white and gray matter), leading to mood swings and psychomotor, language and speed of thought delay (Campbell & Peebles, 2014).). Intestinal disturbances usually occur when the body tries to compensate for the lack of food, increasing the likelihood of constipation, bloating and abdominal discomfort (Campbell & Peebles, 2014).

Fairburn and Brownell (2002) pointed out some strange behaviors in AN as using a dessert spoon to eat soup, dirtying the plate, and hiding food. On the other hand, it is common for individuals with AN to develop a curiosity for cooking justified by the need to control what they eat (Fairburn & Brownell, 2002). This sense of self-mastery works as an escape, showing that if they control their body and weight, they also control their weaknesses (Fairburn & Brownell, 2002).

An issue of some curiosity was conveyed in the study by Lock and colleagues (2015), suggesting that individuals with AN demonstrate a greater tendency to wear loose clothes or many clothes, claiming to be cold, which on the one hand, relieves tension in the face of weight and body shape, but, on the other hand, reveals shame and increases body dissatisfaction, assuming inappropriate and dangerous behaviors, as well as avoiding places where physical appearance is inevitable. Similarly, Fairburn and colleagues (2003) indicate another behavior that affects the quality of life of individuals with AN, namely compulsive analysis, that is, checking their body and weight several times, which leads to ruminating thoughts (“I am fat,” “I am not perfect”), generating greater body dissatisfaction and excessive concern about losing weight.

Given that the consequences of AN in the lives of adolescents are significant, significantly impact their mental and physical health and may even lead to death, multidisciplinary and innovative treatments are necessary.

3.3.4. Psychotherapeutic treatment: narrative therapy

Psychotherapy plays an essential role in the treatment of AN. However, the action of a multidisciplinary team (psychologist, psychiatrist, nurse, nutritionist, endocrinologist, and social worker) and holistic treatment is essential. The intervention must be an integrated effort to achieve the significant objectives of treatment: nutritional recovery, improvement of body image distortion and elimination of compensatory behaviors (Claudino & Zanella, 2005; Duchesne & Costa, 2018). Along with these objectives, the authors also suggest increasing the client's self-esteem, improving their interpersonal relationships, helping with emotional control, and deconstructing negative beliefs associated with food and appearance. The multidisciplinary team approach is crucial for all the affected dimensions (Duchesne & Costa, 2018).

The main theoretical framework in the literature in cases of AN is Cognitive–Behavioral Therapy (Linardon et al., 2017). Thus, we believe that Narrative Therapy (NT) also conveys very positive results, considering its philosophy and given that it is also contextualized as a recent dimension of the cognitive model (Chimpén-López & Muñoz, 2021). Robbins and Pehrsson (2014) add that NT allows clients to understand themselves internally while facilitating access to their unconscious and meaningful cognitive processes.

The practice of NT with AN adolescents promotes an understanding beyond the traditional etiology of AN; that is, rather than exploring biological and psychological factors, it focuses on the cultural, social and writing experience, exploring the emergence and the maintenance of the disorder (Robbins & Pehrsson, 2014). In recent years, with the excessive use of social networks, the desire to be thin has been greatly amplified (Broering & Scherer, 2022). Thus, NT intends to work with life projects, with the values and intentions that guide individuals’ lives, picturing them as protagonists of their history and empowering them. The psychologist/psychotherapist conveys that his/her narrative can be written and rewritten toward the transformation of the dominant negative narrative. Here the main character is not the problem, reaching out (through writing exercises) to an alternative, a more positive narrative filled with hope, new capacities and more flexible and realistic modifications (Robbins & Pehrsson, 2014; Torres & Guerra, 2002; White, 2012).

NT pretends to help adolescents with AN to look at their condition from different perspectives, as well as explore past and present critical moments in their lives – relationships, memories, and turbulent moments – through externalizing conversations, as several studies suggest (Chimpén-López & Muñoz, 2021; Robbins & Pehrsson, 2014). The externalization of the problem allows its separation from the individual; the narrative is transformed into the adolescent is not anorexia; anorexia is anorexia (Chimpén-López & Muñoz, 2021; Robbins & Pehrsson, 2014). The individual-problem separation process is central to achieving new visions. Thus, AN might be seen differently by the individual, reducing the impact of the disease on his/her life and reducing guilt and pressure (Robbins & Pehrsson, 2014). According to Robbins and Pehrsson (2014), the externalization technique will blame only the problem. It may promote a new direction to psychological intervention, such as analyzing the history of the disturbance, its guiding lines, and its results. On the other hand, the intervention assumes looking at/exploring the individual himself, that is, the history prior to the AN and, once again, its lines of action and its results (Robbins & Pehrsson, 2014). It is, therefore, possible to conclude that externalization of the problem allows two therapeutic paths: exploiting the influence of the problem on the individual's life and discovering the individual's life without the influence of the problem; in which this second path can lead to the development of alternative narratives (Torres & Guerra, 2002).

Through the narrative therapeutic approach, it might be possible to identify various situations to understand better the behaviors and thoughts that led to the AN while allowing the client to identify crucial moments of his/her life journey (Chimpén-López & Muñoz, 2021). The narrative process will raise stories that the client himself may have forgotten, but, as indicated by White (2012), are characterized as crucial points for the treatment. According to Adler and colleagues (2007), writing in a therapeutic context is highly beneficial. Narrative writing is correlated with well-being, coherence, and flexibility; that is, narrating about a specific situation as the body changes will enable the adolescent to know themselves outside the disease, interpreting and positively integrating life events (Adler et al., 2007). Writing might influence adolescents with AN into a new perspective of life hope (Robbins & Pehrsson, 2014).

A therapeutic technique linked to NT is poetry, which is beneficial in writing and identifying themes to be addressed throughout the treatment (Robbins & Pehrsson, 2014). Considering the characteristics of AN, like feelings of non-fulfillment and isolation, the literature confirms that using poetry helps to overcome these aspects, improving individuals’ capacity for expression and assertiveness (Robbins & Pehrsson, 2014). Therefore, poetry is seen as a narrative, as it also allows knowledge processing of the individual's history, offering therapeutic branches to intervene and explore (Robbins & Pehrsson, 2014).

Three fundamental phases are enshrined in NT: deconstruction (locating the problem outside the adolescent through externalization technique); reconstruction (construction of new interpretations and meanings for the problem, leading to the development of alternative narratives); and consolidation (the period in which the adolescent recognizes that she/he is more than her/his problem, achieving impressive results, that is, exceptional moments, away from the problem; Chimpén-López & Muñoz, 2021; Torres & Guerra, 2002). As previously stated, externalizing conversations are widely used; they are predominant in transforming the dominant narrative, thus entering the second phase (White, 2012). According to Torres and Guerra (2002), any change obtained in the deconstruction stage must be considered, as it may initiate a new narrative near the consolidation phase.

Throughout the psychotherapeutic process, it might be possible to understand the main guidelines of the client's life, on which we can work through narratives (White, 2012). According to White (2012), basing an intervention on NT leads to the cultural aspects in which the problem is maintained. The psychologist who adopts a narrative approach will not discriminate against AN but understand what this disorder means for the individual and how it influences his/her life (Lock et al., 2014).

Several aspects should be addressed in the psychological intervention using NT: the thin ideal, body dissatisfaction, perfectionism, and family conflicts (Fairburn et al., 2009). However, before this other content-focused approach, it is urgent to establish a therapeutic relationship where the psychologist could provide a safe environment and a more realistic view (Treasure & Schmidt, 2013). Here, the critical focus is patience, affection, empathy, and trust (Araújo, 2012). Research done by Hall et al. (2012) mentions the presence of practical principles for the therapeutic bond, in which the psychologist is seen as a facilitator, adopting a non-confrontational perspective, disclosing what is essential in dealing with adolescents with AN since they have much resistance from interaction and adherence to treatment. The psychologist-client relationship is a co-constructed process where the psychologist explores unknown issues and dimensions (Torres & Guerra, 2002).

The primary focus of the psychological intervention process is the reduction of dietary restrictions and intense physical activities; the adjustment of perception of the body; the modification of inappropriate beliefs and behaviors related to appearance and food; improvement in interpersonal and social performance and self-esteem (Claudino & Zanella, 2005). Following this reasoning, Almeida et al. (2018) claim the importance of addressing two essential processes for adolescents with AN, namely, self-esteem (a value dimension of the self, which is significantly low) and self-concept (the image of him/herself, which in the presence of the disturbance is significantly damaged, due to social comparisons). Psychotherapeutic work addresses these emotional dynamics and other symptoms, such as anxiety, depression, and the feeling of incapacity (Rezende, 2011), which can be modified into alternative, more positive narratives. In addition to these intrinsic aspects, weight regaining is crucial in treating AN, as this physical aspect improves emotional and general health dimensions (Marchili et al., 2016).

Individuals with a deficit in self-knowledge mean that psychotherapy might help the patient discover his/herself – desires, life projects, feelings – something that was once interrupted when the disturbance appeared and could be redefined (Morgan et al., 2002).

Treating individuals with AN is very challenging, given that it is an ego-syntonic disorder; that is, the patient does not desire to change his weight (Duchesne & Costa, 2018). Therefore, the start of the intervention may occur late due to the lack of knowledge of the severity of the clinical condition (Mitchel & Crow, 2006). It is a fundamental reason to put light on this topic in the scientific community and discuss new and innovative approaches (like Narrative Therapy) to address this psychological problem. According to Mitchel and Crow (2006), there is a significantly long distance between the identification of symptoms, the search for help, and the initiation of a multidisciplinary intervention. In the same line of reasoning, other essential points to alert are the high levels of withdrawal from treatment and the various relapses, which, in its extreme, can lead to death (Satir et al., 2011).

The cure for AN is very time-consuming and difficult to embrace, as it implies regaining weight, something frightening for the client due to their rigid beliefs about food and body image (Morgan et al., 2002). Based on the severity of the disorder, there are different levels of treatment, from home to hospitalization (Satir et al., 2011), varying from individual to individual.

Positive and preventive reflections for AN should be the main goals for psychotherapists, social workers, doctors, and nurses. Promote physical activities unrelated to the body’s appearance, create a safe social and family environment and healthy acceptance and validate experiences, all contributing to a positive body image (Piran, 2015).

4. Discussion

Times have changed, and being considered fat has become the target of negativity, ending the era of “fat is beauty”. Over the years, the standard of beauty has changed, and what was previously considered acceptable is now characterized as “ugly,” “disease,” and “shame,” making thinness a goal to be achieved. There is a great emphasis in AN on adolescence, given that it is characterized as a troubled stage of life where individuals start their self-knowledge process, overcome biopsychological changes, and initiate relationships independent of their parents. In this period, peer interactions are established, so it is “doing everything to be accepted” and “to be considered cool.” Specifically, it is usual for girls to follow fashion trends and standard bodies, damaging their self-image just because they do not have what social networks transmit. Variables such as economic success, happiness and attractiveness are associated with thinness and visibility. Adolescents who follow this reasoning do not feel satisfied with themselves, adopt strict diets, and believe that this is the only way they will be included in society.

Given the present historical time, it is impossible not to mention the pandemic. According to Walsh and McNicholas (2020), several obstacles were experienced by adolescents with AN during COVID-19, namely the inability to “escape” from parental control during meals and the inability to leave the house to exercise. On the other hand, advantages were also felt, like adolescents remained isolated at home and reduced social comparison (Walsh & McNicholas, 2020).

Nowadays, a developing idea is portraying inclusive Fashion. Fashion trends are advertised within the current aesthetic standard, mainly by thin models. It provokes, from the outset, desires in teenagers to become equal and to, inevitably, dress identically. Individuals who do not wear those clothes are not in Fashion, not only in terms of clothing but also at a social level, as they are excluded from an image-based society (Busch, 2018). Therefore, being “in and out of fashion” implies inclusion and exclusion. Making a difference starts with fashion designers, who play a fundamental role in this construct, as they must develop sustainable work not only based on thin silhouettes (Busch, 2018) but include all silhouettes. NT also plays a crucial role in this dimension, as it perpetuates different perspectives of what is seen as the main problem by clients, making them understand that there are other essential aims in their lives, creating alternative narratives through the transformation of the dominant ones (White, 2012).

Another important subject is self-knowledge. As mentioned throughout the work, individuals with AN do not know themselves enough to guide their lives positively and constructively, belittling themselves daily and completely distorting reality. Hence, it is crucial to emphasize the importance of self-knowledge. In addition, NT lives up to the notion that the individual himself is the one who has a greater understanding of his/her situation, so he is the leading element in the treatment of this disorder (Lock et al., 2014).

Disclosure statement

Petra José Pereira Santos, Luísa Soares and Ana Lúcia Faria, authors of the manuscript entitled “Narrative Therapy as an innovative approach to Anorexia Nervosa treatment: a literature review,” declare that we have no financial, commercial, political, academic, or personal conflicts of interest.