Group Therapy for Eating Disorders

Sharing the pain and the promise in group

Group therapy is frequently mentioned as a useful treatment method for eating disorders. Group can be a crucial aspect of treatment for many eating disordered patients yet contraindicated for others. For example, many anorexics seem to have poorer outcomes than bulimics with group therapy, partly due to the fact that they tend to be more rigid, withdrawn, and anxious, and also have extreme difficulty identifying and expressing feelings. However, many anorexics have had valuable group experiences that have indeed helped them overcome these obstacles. Although group is not appropriate for every person, those for whom it is seem to benefit greatly from it.

This chapter will serve as an overview and summary of the various issues involving group therapy in the treatment of eating disorders, from why it works to variations on group structure, philosophy, and settings.

WHY DOES GROUP THERAPY WORK?

EDUCATION

Group therapy can be a good forum to educate patients on important topics that may not be addressed elsewhere, such as nutrition, medical consequences of laxative abuse, or assertiveness techniques. Educating patients in group saves individual therapy time for more personalized and deeper issues. Group members also educate each other from their varied experiences in identifying and solving problems. Each group session can be educational, psychodynamic, cognitive behavioral, or a mixture of all three.

UNIVERSALITY

By sharing with and listening to others, patients learn that they are not alone in their suffering, their feelings, and their experience of having an eating disorder. Even though individual stories vary and patients are all unique, a camaraderie exists among people who are suffering from eating disorders. It can enhance a person's self-esteem just to realize that she is neither crazy nor alone. Some patients handle certain issues better than others, and they help each other in this way. Furthermore, a common trait in individuals with eating disorders is the desire to be special and unique, and the eating disorder helps provide that. In a group of peers also with eating disorders, patients must explore and find other, more constructive ways to be unique.

SUPPORT AND ACCEPTANCE

All people benefit from being accepted and cared about, even if they need to make changes. Eating disordered patients often feel or have been rejected by their families and others, and the only support system they feel they can count on is the therapy group. In a positive group therapy experience, group members provide acceptance while at the same time supporting and encouraging necessary changes. Through a positive group experience, patients can learn compassion and empathy for others and then extend this compassion and empathy to themselves.

INTERPERSONAL RELATIONS

Often patients have lost or never acquired the necessary trust or interpersonal skills to develop quality relationships. With the help of other group members, patients can learn what their feelings are and how to communicate them. Patients who otherwise have a hard time forming relationships can eventually learn to share, get close, trust, love, and be loved.

CONFRONTATION

If group therapy always consisted, session after session, of everyone being nice and encouraging, it would not only get boring, but very little growth would take place. Once an atmosphere of trust and caring is established, the therapist facilitates group members in confront- ing each other about inconsistencies, self-destructive behaviors, and issues of disagreement. The therapist's task is to help patients learn to challenge each other in a caring manner, so they learn that they can like or love someone and yet disagree or question them at the same time. Many eating disordered patients don't know that it is okay to get mad, discuss negative feelings, and argue, and that it is how you go about it that makes the difference.

FRIENDSHIP

A controversy has existed over whether members of groups should have outside contact with each other. The early proponents of group therapy had the philosophy that group is meant to help patients learn how to make friends, not provide friends for them. Many female therapists, notably Dr. Melanie Katzman, have spoken out in books and at national conferences disagreeing with the early concept of "no outside involvement" between group members and instead encourage therapists to promote group members' using each other outside the group for support. Being in a group is obviously a good way of reaching out, contacting others, and developing personal resources. Patients need each other this way. Sometimes just a phone call can prevent a binge, bring someone out of a depressed mood, or offer an alternative to throwing up. If patients agree, names and phone numbers can be exchanged in the beginning, and members can call each other between group sessions. Some members may even form friendships that remain long after the group has ended. It is up to the therapist to recognize and effectively deal with any splitting or undermining effects that outside contact or friendships have on the group.

TYPES OF GROUPS

When forming an eating disorder group, there are decisions to be made about what kind of group it will be. Will you separate patients by disorders, will you allow new patients after the group has been going on for a while, or will you simply have a drop-in group?

SEGREGATED/HOMOGENEOUS GROUP

A segregated or homogenous group includes only people with the same disorder; for example, all anorexics, all bulimics, or all binge eaters. This method of group member selection is used to enhance the similarities among members and avoid the issue of members not relating to one another. Anorexics and binge eaters often complain about being mixed in groups together, as they feel they cannot relate to each other. They suffer from different illnesses.

Many experts agree and don't mix them in groups. However, heterogeneous (mixed) groups have certain advantages and can be very therapeutic. For example, in a group of all anorexics, the egocentricity, hypersensitivity, and anxiety can be so high that it can make group interaction impossible. The competition in a group of all anorexics, all wanting to be the best anorexic, comparing notes on who ate less or weighs less, and so on, can overshadow any potential benefits. Depending on the skills of the therapist and available patients and patient selection, mixed groups may be a better alternative.

MIXED/HETEROGENEOUS GROUP

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The most common heterogeneous group of eating disordered patients consists of anorexics and bulimics. Anorexics and bulimics have so many similarities that they seem to accept fairly readily being mixed in a group setting. Groups with anorexics, bulimics, and binge eaters are also prevalent, especially in many inpatient treatment programs. The working premise is that all of these patients have an unnatural or self-destructive relationship with food and their bodies. Combining groups may provide a more difficult task for the therapist, but potential benefits are exceptional when the group works. Hearing horror stories about the pain and agony of an anorexic often helps bulimics to not want that for themselves and vice versa. Patients can look at each other's strengths and weaknesses and even, strange as it might seem, see themselves in each other and see the many common themes or underlying psychological issues they share that contribute to their dysfunctional relationships with food and weight. Mixed groups provide experiences that break through distortions in thinking in a way that the therapist or another similar patient cannot. For example, Mary, a binge eater, said to Pam, an anorexic, "How could you sit there and say you are fat? I am fat. If you feel fat, that's one thing, but to say you are fat is wrong."

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By Carolyn Costin, MA, M.Ed., MFCC, Medical Reference from "The Eating Disorders Sourcebook"

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