A paraphrase by Lois Shawver of

Externalizing the Problem and

Internalizing Personal Agency
by Karl Tomm, M.D.
from the
Journal of Strategic and Systemic Therapies. 8(1), spring, 1989, 54-59

Selected passages in the paraphrase are quotations for the

original document. these are indicated by italics.
A gifted therapist, Michael White, has created a psychotherapy technique I will try to explain. The
technique is called "externalizing the problem." Externalizing the problem requires the therapist to use
the language in the session carefully in order to mobilize the patient's initiatives in self-healing. When
it is done well, externalizing the problem can be used to ameliorate a wide range of serious problems
including schizophrenia, depression, paranoia, violence and suicide risk.
The idea of externalizing the problem began about ten years ago when Michael White made a simple
but significant discovery. He was working with children who had not mastered bowel control at the
usual age , and he invented the word "Sneaky Poo" to refer to the problem (encopresis) when he talked
with the children about it. In this way, in personifying the problem, he "externalized it" so that it was
talked about as an entity separate from the child. In the therapy dialogue, the child might be asked
questions like: "Have you ever had Sneaky Poo sneak up on you and pop into your pants when you
were busy playing?" "Have you ever beat "Sneaky Poo?" Eventually, the problem is thought of as
"Sneaky Poo's" and not the childs and then the parents have less reason to criticize and blame the child
or to blame themselves. The parents have less reason to blame the parents....It opens a space to
explore new efforts in problem solving. Since everyone is under the influence of the same
'troublemaker' and family members are no longer pitted against each other, it is easier for the child and
parents to "join forces in beating sneaky Poo" As a result, the therapeutic process proceeds more
quickly.
A version of this treatment process has been used with many other kinds of problems. For example,
White (1987) describes how it is possible to externalize "schizophrenia." This externalization does not
become a rigid static frame. It is an ongoing construction that systematically removes the troubling and
pathologizing aspects of the problem.
The reason this process is so healing is that it is an effective antidote to an inadvertent but ubiquitous
pathologizing process in human interaction, i.e., negative labelling....[I]t a very useful therapeutic
technique that opens space to "undo" some of the negative effects of social labeling.
But there is an even more powerful benefit of externalizing. Once a problem has been externalized the
client is invited to escape the oppression of the labelling and to set their lives in the direction that they
prefer (White, 1987). Clients are asked questions like: How ready are you to take a further step against
the voice of anorexia? In that new ways to combat anorexia are envisioned in the therapy, the client is
not left feeling helpless. No pressure is brought to bear on patients to take a particular course of
action. What is emphasized and brought forth in the therapeutic conversation are the alternatives that
might be available to them.
Another important feature of the method is that the problem is externalized from the person and not
projected onto someone else. Thus the liberating protest and rebellion is not against other persons.
Consequently, significant others in the patient's social network are less likely to be triggered into
defending themselves and are less likely to respond by blaming, relabelling and re-pathologizing the
patient.
Finally, when constructive steps are taken, they need to be recognized and responded to, in order to
become part of a healing identity. This is necessary if the constructive changes are to persist. Clients
need to be asked questions like: What did you do that made it possible for (the constructive event) to
take place? How did you manage to take this step forward?
White's process of externalizing theproblem is not entirely new. In some respects it captures some of
the ancient religious wisdom of demon possesion and exorcism. But it demystifies the process and
utilizes it in a rigorous and precise manner. ....
At present, evidence of the effectiveness of this new method is mainly experiential and anecdotal.
Nevertheless, in the last few years White's approach has had a major impact on patterns of clinical
practice in Australia and New Zealand. It is now beginning to be introduced in North America and
Europe and has already been taken up by a few centers. ....
White's work offers a useful new technique for day-to-day psychotehrapeutic practice. It is respectful
and humane, and in my opinion, is among the most exciting new developments in psychiatry in the past
decade...
White, M. Family Therapy and Schizophrnia: Addressing the In-the-corner Lifestyle. Dulwich Centre
Newsletter, 1987.