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The
British
Psychological
Society

Psychology and Psychotherapy: Theory, Research and Practice (2010), 83, 243254
q 2010 The British Psychological Society

www.bpsjournals.co.uk

Living with the anorexic voice: A thematic


analysis
Stephanie Tierney1* and John R. E. Fox2,3
1

School of Nursing, Midwifery and Social Work, University of Manchester, UK


Division of Health Research, Lancaster University, UK
3
Eating Disorders Unit, Russell House, Affinity Healthcare, Cheadle Royal Hospital,
Cheshire, UK
2

Objectives. A factor said to drive the behaviours of people with the eating disorder
anorexia nervosa is the inner voice some recount hearing. However, little systematic
examination has been made of this entity. The study aimed to investigate experiences of
and reflections on living with an anorexic voice.
Design. A qualitative approach was used because the study sought to establish the
perspectives of those with anorexia who identified with the concept of living with an
anorexic voice.
Method. Individuals from three self-help organizations were invited to write about
their life with an anorexic voice in the form of a poem, a reflection, a letter, or a
descriptive narrative. Recruitment continued until data saturation was reached.
Thematic analysis was employed by two researchers.
Results. Written contributions were provided by 21 participants. These data
underlined the positive and negative attributes individuals bestowed upon their
anorexic voice; the former appeared stronger during the early stages of their eating
disorder, the latter coming into force as it developed. In spite of their voices harsh and
forceful character, participants felt an affiliation towards it.
Discussion. The bond between individuals and their anorexic voice could explain
their ambivalence to change. Therapists must persist in their endeavours to penetrate
this tie, whilst acknowledging the hold this entity has over those with anorexia.
Interventions that address this component of the eating disorder could prove fruitful in
helping people towards recovery.

People with anorexia nervosa (AN) have a reputation of being hard to treat (Vitousek,
Watson, & Wilson, 1998), accounting for the negative view of working in this area
articulated by some professionals (Burkert & Schramm, 1995; Williams & Leichner, 2006).
When the disorder is regarded as dysfunctional, as constituting a form of self-harm,
* Correspondence should be addressed to Dr Stephanie Tierney, School of Nursing, Midwifery and Social Work, University of
Manchester, University Place, Oxford Road, Manchester M13 9PL, UK (e-mail: stephanie.tierney@manchester.ac.uk).
DOI:10.1348/147608309X480172

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244 Stephanie Tierney and John R. E. Fox

those around naturally attempt to rescue the individual, becoming frustrated and
sometimes annoyed when she/he appears resolved to persist with a seemingly
destructive life-style. It has been argued that although those with AN may be aware of
the precarious nature of their physical status, they can be fearful that parting with
their ego-syntonic symptoms will throw them into an even deeper state of distress
and confusion (Garner, Vitousek, & Pike, 1997, p. 100).
In a Delphi study by Tierney and Fox (2009), practitioners listed as a key concept in
understanding chronic/enduring AN that an individuals sense of self had come to be
defined by the condition. Likewise, a grounded theory project of illness perceptions in
AN found that interviewees held dual beliefs about their eating disorder, seeing it both as
providing a sense of self and a separate illness (Higbed & Fox, 2010). Participants in
the study spoke of how their AN had a voice, which appeared to be an important
phenomenological aspect of the condition. This notion of the anorexic voice has been
supported in personal accounts written by those with AN, who have described how
such an entity compelled them to push their body to its limits (Fathallah, 2006;
Hendricks, 2003). Anecdotal evidence implies that this component of the disorder can
have a strong impact on actions.
Rationale for the study
Little systematic inquiry has been conducted about the views of individuals with AN
in relation to their inner voice and how it affects their journey towards recovery. The
study described below attempts to fill this gap. Prior to data collection, based on their
personal and clinical experiences, the authors anticipated that participants would
show some degree of attachment to their inner voice and would disclose the
powerful influence it had on their thoughts and behaviours. This has been reported in
the existing literature relating to voice hearers generally, carried out by Romme,
Escher and colleagues (Escher, Romme, Buiks, Delespaul, & van Os, 2002; Honig et al.,
1998; Romme & Escher, 1989, 1994; Romme, Honig, & Noorthoorn, 1992). It has
been suggested that non-patients who hear voices can experience both companionship and distress from such entities (Romme & Escher, 2000) and can perceive them
to be predominately positive, if they feel in control (Honig et al., 1998). Strategies
reported for managing these voices have included distraction, ignoring, selective
listening, and limiting their influence (Romme et al., 1992). Whether those
experiencing an inner anorexic voice are similar in this respect remains to be
investigated.

Methods
Aim
The research aimed to investigate peoples encounters with and reflections on
living with an anorexic voice because it was felt that this could have an impact on
their experiences of this condition and their ability to change. Qualitative research
was employed, a form of inquiry that adopts a naturalistic interpretative approach
concerned with understanding the meanings which people attach to phenomena
(actions, decisions, beliefs, values etc.) within their social worlds (Snape &
Spencer, 2003, p. 3). Approval for the study was obtained from the School
of Nursing, Midwifery and Social Works (University of Manchester) Research
Ethics Committee.

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Anorexic voice

245

Sample
Three UK-based self-help organizations for those with an eating disorder assisted with
recruitment. Investigators sent details about the project to a contact person, who
notified members electronically or via word of mouth. Those interested in taking part
were requested to contact the first author for a research pack, which included further
particulars about the project, consent forms, and a background questionnaire. They
were asked to return this information to the research team, along with their
contribution to the study, in a prepaid envelope. People were invited to take part if they
currently or in the past had AN and if they identified with the notion of an inner anorexic
voice. Only those 16 years or older were eligible to take part.
Data collection
Within the information sheet sent to participants, the following instructions were listed:
Please give an account of what it is (was) like for you to live with an anorexic voice.
This could be a record of a conversation with it, a description of your experiences of
living with it, a poem reflecting on this part of your eating disorder, or some artwork that
sums up what it is like for you. If you are going to produce a written account, please
limit this to no more than 1500 words. It can be a lot less than 1500 words this is just
a maximum amount.

A single reminder was sent to those who had not returned their contribution within
1 month. Data were collected between January and April 2009. In this paper, only data
from written accounts (which formed the majority of contributions) will be reported
on. A later paper will discuss the artwork provided by participants.
Data analysis
A thematic approach was used for analysis (Braun & Clarke, 2006), which strove to identify
key concepts present within participants contributions. Initially, the two authors read
material and made notes about the main issues they felt were present in the data. They then
met to discuss their views and to develop a coding scheme, after which the first author
coded each contribution, storing data on the qualitative computer program Atlas-ti to
facilitate with managing and retrieving information. The authors met once again to discuss
the codes and to collapse them into categories presented in this paper.
Reflexivity
The first author of this study (S. T.) is a White British woman, who has been researching
the topic of eating disorders for approximately 8 years. She has personal experience of
AN, having lived with the condition during her teens, and has run eating disorder support
groups. The second author ( J. R. E. F.) is a White British male. He has considerable
experience of clinical work as a psychologist treating people with AN and has conducted
several qualitative studies on this topic. As suggested above, there were regular meetings
between the authors, during which they discussed data and emerging themes, and were
able to reflect on how their backgrounds might impact on their interpretation of data.

Results
In total, 37 people (all female) requested a copy of the research pack. Two had to
be excluded because they were 15 years old. Thirteen people failed to return

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246 Stephanie Tierney and John R. E. Fox

a contribution. Of the 22 supplying data, all but 1 provided a written description of their
life with an inner voice. This paper is based on these poems (N 8), letters (N 2),
and reflections/descriptive narratives (N 11). Mean age of those making a written
contribution was 22.1 years (SD 6:1). In terms of weight, their mean current body
mass index (BMI) was 17.1 (SD 2:1) and their mean lowest adult BMI was 13
(SD 1:7). All but two defined themselves as White British and most (N 18) were
students or not working. Based on their BMI, over half (N 12) currently fell into the
weight range to be classed as having anorexia (BMI # 17:5). However, even if weight
recovered, anorexic thoughts may continue to plague individuals who have
experienced this condition (Tierney, 2008).
Preliminary analysis by the authors resulted in 135 codes. These were entered into
Atlas-ti and then discussed and grouped into the 10 categories listed in Box 1. Many
initial codes could easily be combined as they were similar in nature. For example, the
initial codes provides advice, decision maker, shapes behaviour, stops her taking
risks, and driving force were brought together to form the second category shown in
Box 1. To develop these 10 categories, each of the 135 labels was listed on a post-it note
and then grouped if felt to be related.
From this process of categorization, a clear idea emerged relating to the perceived
positive characteristics (e.g., friendship, comfort, protection, motivation) that
participants attributed to their voice, characteristics that seemed to undergo a
metamorphosis as their relationship with this entity developed and it assumed a more
sinister form (becoming a tyrant, a captor, a manipulator, and a bully). The following
section chronicles this process, as recounted in participants contributions and is
illustrated in Figure 1.
Stage 1: Being drawn into the relationship
Participants wrote about how the voice gradually entered their life at a time when they
felt particularly vulnerable. It arrived with a plethora of endearing qualities; it was a
source of comfort, a distraction from other problems and from painful emotions.
Participants described how it brought order to their life and assisted them in decision
making:
Participant 11: You just started setting rules and straightening things out. Like a military
campaign you obliterated the initial confusion and laid out the borders and barriers. You put the
messiness of life into tiny compartments, each one boxed and labelled and managed in turn.

Box 1. Categories arising from data analysis

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)

Feeling part of something


Giving a steer to life
Providing comfort and safety
Constant presence
Entrapped in an undesirable situation
Attacking sense of self
Demanding and harsh task master
Powerful entity
Dangerous state of being
Breaking free

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Anorexic voice
Stage 1 - Drawn into the relationship
Seen as a solution and a distraction
from existing problems and concerns,
and as reducing a sense of isolation

Stage 2 - Ensnared in the relationship


An inequality and destructive quality to
the relationship develops; positive
attributes of the voice become negative

247

Positive attributes
of the voice
Motivator
protector
comforter
friend

Negative attributes
of the voice

Tyrant
captor
manipulator
bully

Stage 3 - Life without the relationship


Ambivalence to leaving the
relationship when positive attributes
are recalled, yet negative ones come
to dominate

Figure 1. An illustration of how participants perceptions of their voice changed from positive to
negative overtime, although it continued to hold some attraction for them, even as they contemplated
life without it.

The voices words were taken to be the truth, which meant individuals did not
question what it was telling them:
Participant 10: This voice was like my new life coach and I couldnt think of any reason not
to listen to it.

To begin with, the voice offered security, shielding participants from the outside world.
Participant 12 described it as a parent that controlled but was also comforting. Like
a parent, participants drew support from the voices presence, becoming dependent
on it as a source of guidance and advice. It rescued them from feeling lonely by being
ever-present:
Participant 2: As the antithesis of my weak and fractured mind you arrived just when I was
feeling so alone, isolated and confused.

All participants used the term friend at least once to define their inner voice and in this
early stage it was regarded as something they could rely upon.

Stage 2: Becoming ensnared in the relationship


What initially was valued about the voice altered overtime and became something to
despise. For example, its constant companionship started to be perceived by
participants as confining and wearing as it became stricter and louder; having to tolerate
its abuse, in particular, was draining:
Participant 20: when I see myself in the mirror I cry because my head is screaming
dirty fat bitch disgusting failure, not good enough, loose weight you pathetic piece of
crap, worthless, useless idiot, dont DARE eat! Where are the rest of your bones? Dont
DARE eat you fat, DISPICABLE, HIDEOUS waste of space
Participant 21: Imagine every time you try to eat, somebody is screaming in your ear that
you shouldnt and all the reasons why you shouldnt. Taunting and threatening you if you do
eat. If you take a bite it gets louder and angrier.

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248 Stephanie Tierney and John R. E. Fox

Participants described how the voice came to control their behaviours, dictating what
they could and could not do, stopping them from shaping their own existence. It
punished and degraded them for failing to abide by its rules, as the following protracted
abstract, during which a participant recounts the words typically coming from her
voice, illustrates:
Participant 17: The cupboard door will slowly open, creaking softly. Your eyes will move
over the food that I have kept at a safe distance from you. You will find your hands reaching
out, lethargically, like a nightmare, through the darkness to the box of chocolates. You
greedily shove them in, mechanically, not really tasting but simply relishing the fact that you
are going against me. You reach for more and more forbidden treats. Your stomach will
become bloated and swollen, but you will not stop yet When it is over you will cling to
me again and ask for advice because you really dont want to get fat. You broke a cardinal
rule and ate, and now you want me back. Ill force you into the bathroom, on your knees,
staring into the void of the toilet bowl. Your fingers will be inserted into your throat and, not
without a great deal of pain, your binge will come up. Your eyes will water, your head will
pound, your heart will race out of your chest and you will want to give up. But I wont let
you. Over to the laxatives, take the whole strip. You need to know its all gone. When you
have finished, you stand up and feel dizzy. Dont pass out. Stand up right now. You fat cow,
you deserve the pain!

Data analysed suggested that the voice started to demand an exclusive relationship with
the individual and constantly tested her allegiance. It attempted to turn participants
away from people who interacted with them by twisting their motives for trying to
reach in. It urged them to lie to family, friends, and professionals in order to maintain
their disordered eating behaviours:
Participant 18: Everyone is just trying to make you fat, no-one cares about you. You are
no-one without your eating disorder No-one cares about you unless you are dying in
hospital. No-one will help you unless you are life threateningly thin.
Participant 21: It turned me against people. It would tell me: They hate you and you cant
really trust them. Theyll only hurt you. You dont need them. Or it would whisper: Youre
evil and dont deserve them being close to and talking to them will only hurt them. The
only thing you can do right is to lose another stone .

Despite its demand for exclusivity, the relationship was far from equal. The power
individuals felt the voice held was evident in their accounts. It was defined as something
to be feared and obeyed. They strove to avoid its wrath at all costs by bowing to its will.
Its demands became increasingly taxing as it pushed participants to extremes, with its
ever shifting goalposts making it a hard task master to please. It expected perfection in
all aspects of life; any hint of being average was derided:
Participant 2: The perfection you promised had seemed so right at the time; but the longer
I engaged in your project the further away that ideal became. You told me that ordinary was
not enough. That ordinary was banal if I didnt listen I would always be stuck in the
middle, never quite getting there, never quite making the top.
Participant 12: The voice did not congratulate me for obeying anything, nor did it ease off if
I did There was always something I did not do well enough and this was what the voice
drummed into me It made me scared to be alive because every day I had to get up and
face its abuse. I knew I would be challenged further.

The voices vindictive nature was evident in contributions. It criticized and belittled an
individuals actions, attacked her sense of self, made her question her own abilities,

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Anorexic voice

249

slated her as a failure and undermined her self-esteem and confidence. This seemed to
increase participants dependency on their voice, making them believe they were
unable to function without it. References about being captive or a prisoner were made,
as individuals depicted themselves as the voices possession:
Participant 9: Shes stronger than everyone, no-one can win. She has you in her trap from
the moment she drops in.
Participant 16: She keeps me living this half life not alive and yet not dead. Theres no
escape, I cannot hide, not even at night in bed.

Stage 3: Life without the relationship


Sooner or later most participants reported feeling let down by their voice, which they
realized had lied to them about its ability to transform their life for the better. Hence,
they started to question its motives and fairness, and acknowledged the destructive and
dangerous nature of this relationship and the possibility of their death as an end product:
Participant 1: It has pushed me to achieve, to be the best, whatever the cost. It has stunted
my personal and physical growth in its demand for perfection. We are engaged in a dual of
death, in which only one of us can be the victor.

Eventually, a wish to be free from the voice superseded the positive benefits it was
thought to furnish. This resulted in part of the self-starting to take a stand by challenging
its demands. Entering a stage of conflict with the voice in this manner was not reported
to be easy (like killing your best friend, according to participant 15), and was met with
resistance from this entity. However, some participants did note that fighting back
meant the voice was muted and began to lose its grip over them:
Participant 7: Facing recovery meant arguing with the voice more. Feelings of failure, either
towards my family, myself or my anorexic friend, became far more severe. Gradually, these
feelings of failure shifted in favour of my anorexic free life. I began to win arguments with
the voice.

There was a sense of hope in certain narratives that life free from AN was possible, as the
following abstract implies:
Participant 2: There is a part that stands aside. Its a small fragment of light, an urge, a
desire, a chink in which I can place footholds as I go. Is it a part of me that lays outside the
clutches of you, that wont accept that I have given up and want it all to shrink away?
It propels me on. It is the part that essentially allows my body to collect its flesh and hold on.
It doesnt silence you completely but it gets me to step back and contemplate the jump.
I think about crossing the abyss to a life that is free of you. I may not be there yet but I can
see it; and that is my hope.

However, a number of participants appeared concerned about losing the companionship they felt from it, explaining that external attempts (e.g., from professionals and
parents) to enforce a separation caused them pain. They described being fearful of being
without the voice:
Participant 4: This illness has caused so much pain, put so many people under so much
strain. I want to move on and I want to achieve, but Ana keeps refusing to leave Ana tells
me that shes here to stay, that I wouldnt be able to live any other way.
Participant 11: They want to break the connection. They dont realise that Im lost without
you. You are my whole life.

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250 Stephanie Tierney and John R. E. Fox

A sense of loss was experienced by ending the relationship. For some this made
progress towards recovery difficult, but for others a wish to be free became more
important than maintaining this tie. They were able to replace the voice of AN with one
of reason, which included listening to others and accepting their support and help.

Discussion
The rich and complex data collected from women living with or recovered from AN
highlighted that how they viewed their inner voice shifted from positive to negative; it
changed from being a source of comfort to being loud and forceful, demanding
unquestioning obedience. It may be surprising to others that individuals are so
committed to something that frequently launches a full-scale attack on the very essence
of their being, yet as shown in the extracts above, and in other publications (Maisel,
Epston, & Borden, 2004), the voice convinces people that they are fatedly flawed and
that the only remedy is stringent bodily control and self-sacrifice.
Even though it became punitive and critical, many participants continued to be
seduced by their voices promise of a better life. This underscores how the resistance to
change patients often exhibit is not necessarily a display of obstinacy, but a reflection of
the immobilization they experience as life becomes dominated by their inner voice. It
should be noted that this voice appears to dismiss offers of assistance or concern by
others and encourages the patient to question someones reason for trying to intervene,
thus making this a difficult group to engage in treatment (King & Turner, 2000; Williams
& Leichner, 2006).
When steps towards improvement are made, professionals need to be cognizant of
the loss individuals with AN can feel as they contemplate a life no longer directed by
their inner voice. Descriptions analysed for this paper emphasized how participants
were saddened by the possibility of abandoning what they regarded as a friend and a
part of their identity. It may be demanding, but to be without their anorexic voice leaves
patients pondering questions such as: Who am I if I let this go? What will drive my life
now? This links to the protection that participants associated with their voice, a quality
that has been listed by other authors (Gale, Holliday, Trrop, Serpell, & Treasure, 2006;
Nordbo, Espeset, Gulliksen, Skarderud, & Holte, 2006). For instance, in a study by
Serpell, Treasure, Teasdale, and Sullivan (1999), AN was defined as a guardian by
patients asked to write a letter as part of therapy.
Positive attributes bestowed upon AN include its function as a distraction from painful,
negative emotions, a notion supported by data presented above and in previous work
(Higbed & Fox, 2010), which has implied that those with this eating disorder exhibit
emotional dysregulation and inhibition (Holliday, Uher, Landau, Collier, & Treasure, 2006).
The voice could also be seen as a repository for qualities of the self that participants were
unable to correlate with the internal picture they had of themselves; it embodied traits
commonly regarded as unfeminine (e.g., competitive, ruthless, powerful) that patients
may find hard to accept as part of their overall makeup. Similarly, the voice appeared to
enable individuals to experience a sense of superiority. This runs counter to the low selfesteem associated with the condition (Button & Warren, 2001; Shisslak & Crago, 2001) and
is another characteristic that may be difficult to acknowledge, but at the same time
something that is alluring, strengthening the power attributed to an anorexic voice.
Given ANs functional quality, it is unsurprising that conflicts transpire between
professionals and patients (Ramjan, 2004; Tierney, 2008), as the latter is encouraged to

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Anorexic voice

251

fight against something they wish to preserve to an extent. Often it is only when the
demands of the voice are too taxing and it becomes more of a hindrance than a help
that someone takes tentative steps towards changing their behaviours. Written data
collected for the project supports the observation of other commentators that the
weaker it [the voice] gets, the harder it fights (Maisel et al., 2004, p. 177). Hence,
working towards recovery and ignoring its rules and regulations is an uphill and
continuous struggle. Even among those who had made progress, the voice was
depicted as being ready to re-establish its dominance at any moment. Such
susceptibility to its power links to the relatively high rates of relapse found among
those with AN (Berkman, Lohr, & Bulik, 2007) and to the fact that between 10 and 20%
of people with this eating disorder are said to develop an unremitting form (Fairburn &
Harrison, 2003).
Written accounts analysed for this paper underline the central role that the
anorexic voice plays in the lives of those with this eating disorder. Individuals may find
it difficult to progress towards recovery when this aspect of their condition has such a
tight grip over their thoughts and behaviours. It has been noted that psychological
distance between self and AN is required for recovery to transpire (Higbed & Fox,
2010) and that motivation to change can be enhanced by regarding the condition as an
external problem that impacts negatively on quality of life (Goldner & Birmingham,
1994). This process of externalization allows people to recognize and label their
dysfunctional and dangerous thoughts as the voice of the illness (Kleifield, Wagner, &
Halmi, 1996).
Attention to the anorexic voice during treatment may help to improve outcomes and
could include techniques to assist patients in managing their voice, which may always
be present but could be something they learn to gain control over. Role play is one
means of tackling this problem, during which the individual is coached to respond to
their voice more assertively and learns to defend their right to be treated with respect
and dignity (Chin, Hayward, & Drinnan, 2009). Paying attention to this component of
AN would follow changes that have occurred in therapeutic approaches for voice
hearers, whereby an emphasis is now placed on working with individuals to understand
their experience rather than trying to eradicate their voices as a symptom of illness
(Roome & Escher, 2000).
Birchwood, Meaden, Trower, Gilbert, and Plaistow (2000) found that psychosis
patients often have a subordinate bond with their voices, mirroring real-life
relationships. Likewise, participants with AN in the study outlined above, and in
another by Higbed and Fox (2010), detailed how they were dominated by their anorexic
voice. Further research is required to explore whether the voice is reminiscent of any
past or present relationships. If this was the case it may suggest a particular therapeutic
stance to adopt. For example, cognitive analytic therapy, a time limited and structured
approach that integrates a range of psychological models, comes from a standpoint of
self as constituted via interpersonal experience (Ryle, 2004). It places an emphasis on a
collaborative therapeutic relationship and on bearing witness to the patients story
(Kerr, Bikertt, & Chanen, 2003, p. 520). During therapy, dysfunctional relationship
patterns are explored and modelled in diagrammatic form (Treasure et al., 1995).
Narrative therapy, advocated for treating other patient groups (Chin et al., 2009, p. 13),
could also prove useful when working with those who have AN, enabling them to re-tell
the narrative of their experience in a way that emphasizes their own strengths and
locates the problem in the relationship rather than in the hearer. More research
examining the integration of the anorexic voice into therapy is required.

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252 Stephanie Tierney and John R. E. Fox

Interest in the project


The enthusiasm with which participants responded to the call for contributions to this
research was noteworthy. The following comments sent by people requesting a study
pack highlight how much of an issue individuals felt the anorexic voice was for them
in their day-to-day lives and during interactions with practitioners:
Please let me know how I can contribute health professionals are not fully aware
(and obviously can never fully know) what its like to be inside our heads. If this can assist
them to do so then it can only be a good thing.
When I read the request I was immediately interested because I want to make people aware
of the inner voice that lives inside someone with an eating disorder, and squash the
stereotype that its all about being thin .

This denotes once again the important role engaging with this entity could play in
therapy. Penetrating the bond between an individual and their anorexic voice can be
difficult; as noted in the results above, people become closed off from the outside world,
focusing their energies on obeying and pleasing their voice. Therapists need to persist in
their endeavours to infiltrate this relationship, but must also be conscious of the
perceived control patients ascribe to their inner voice, which may influence strongly
their responses and activities.
Limitations
This study was based on data provided by individuals accessed via self-help
organizations, who self-defined as experiencing an inner anorexic voice; diagnosis
was not confirmed by more objective measures, although to be able to write about an
anorexic voice in the way that participants did implied that they had experienced or
were living with AN. In addition, most individuals alluded to professional care they had
received for their eating disorder within their contribution. Many similarities occurred
within their descriptions, suggesting commonalities in participants appreciation of this
concept. Nevertheless, future work could recruit patients via specialist services, to
compare the views of those classed as recovered and those who still have an active
illness, although as noted above, just because someone is no longer compromised
physically does not mean that they do not continue to be haunted by anorexic thoughts
(Tierney, 2008).
The sample size was limited but did enable some key themes to transpire, providing a
starting-point for understanding peoples beliefs about their anorexic voice and the
impact this entity has on their thoughts and behaviours. Further work, looking at the
views of males with AN and those from ethnically diverse backgrounds, would
complement and add to the emerging picture presented in this paper. Additional
research could also investigate how the experiences of people with AN compare to those
of other voice hearers, and explore the opinions of those with the condition towards the
concept of being a voice hearer (i.e., is this something they would shun as a selfdefinition, fearing that it is regarded as a socially unacceptable identity?). More work in
this area is warranted to advance our knowledge and to better assist those living with AN.
Conclusion
This paper outlined the influence an inner voice can play in the progression and
management of AN and how it may contribute to the difficulties therapists often
experience in encouraging people to change their disordered eating behaviours and

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Anorexic voice

253

thoughts. Patients with AN may display ambivalence to altering their situation, which
could relate to the positive and negative characteristics they attribute to their inner
voice. Acknowledging its presence and discussing this entity in treatment could assist
patients in their journey towards recovery. It is hoped that providing an insight into the
dilemmas experienced by those with AN will make professionals more accepting of
those with this eating disorder. People who are lonely and find it difficult to manage
negative emotions may be susceptible to the voices charm, as it offers them an answer
and gives some meaning to their life. These individuals need help to trust others and to
turn to external sources for support.

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Received 17 July 2009; revised version received 21 October 2009

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