Group Therapy for Eating Disorders

continued

MEMBER PREPARATION

It is necessary to prepare participants for the group experience. It is the therapist's job to clarify what group therapy is and the purpose of the group. The therapist must clarify any misconceptions, guide members in what to expect, discuss fears, and provide support. It is important that the therapist set up some definite structures even if the group helps out with some of the planning. Especially in an eating disorder group, structure needs to be provided and ground rules set. Handouts on group rules and guidelines are useful.

Some rules are general and apply to all groups, for example, the rule of confidentiality. Depending on the kind of group, the therapist or the group will decide what to do about tardiness, absences, and so on, but all of this is ultimately the therapist's responsibility. The next section discusses some ground rules that should be given out at an initial group meeting.

GROUND RULES FOR GROUP

The patients will look to the therapist to establish the norms. It is the therapist who establishes the code of behaviors or norms that guides the interaction in the group. The therapist guides the interaction by modeling, encouraging, and teaching when appropriate.

An obvious example of this is the need for the therapist to redirect questions and dialogue from herself to other members of the group. For example, in the early phase of a group, a therapist was talking to an extremely emaciated, anorexic girl about being cold. She was shivering, yet everyone else was quite comfortable. The therapist told her this was due to the fact that she was too thin and had no insulation or protection from the cold. Another female member of the group asked the therapist, "Does it bother her when you say that?" It is the therapist's responsibility, unless someone else in group does it, to redirect this member to ask the question directly to the person being talked about or to make a statement to the therapist regarding her feelings about the therapist's actions, such as "It bothers me when you talk to her like that."

Redirecting dialogue is necessary to get the group dealing with each other, and it is one example of the therapist's function in setting desirable standards, such as high level of involvement between group members, nonjudgmental acceptance, high level of self-disclosure, a desire for self-understanding, and a desire for change.

One important standard the therapist sets is the importance of process over content in the group. In running an eating disorder group, members could spend the whole session discussing a topic such as "perfection." Each person could take turns, or there could even be interaction among the members, but all are likely to stick to their own experiences of this topic. This kind of interaction is content oriented. It is important, if the group is to be a true therapy group, to include process interaction, discussing the here and now. "How do you feel about what she just said?" "You look like you don't believe Sherry." "You look nervous and unhappy about that." Mem-bers, unless redirected, may continue blindly with content interaction unless the therapist establishes the understanding that process is just as, and probably more, important.

How the group members feel about and relate to each other is of the greatest importance. What group members are thinking and not saying is exactly what they should be saying. The therapist can simply stop periodically and ask a member or members what they are thinking right at that moment, or ask what they have thought about but have not said so far during the session. The therapist must encourage the group members to ask questions of each other. Keeping journals and writing about the group sessions is a good way to bring process interaction into the group. In the journal, members will express much of what they were really feeling during a session. If they are willing, participants can read what they've written at the next group session. This usually brings up important feelings and leads to a good process discussion. Eventually group members start to bring up process comments on their own during the group session.

It is also important to establish guidelines and rules for things like refraining from drugs and alcohol before group, ways that payments and missed sessions are to be handled, punctuality, and confidentiality.

GROUP TOPICS

Below are some topics or themes useful in eating disorder groups. They can be distributed at the first session to provide guidelines as to what the group will be concerned with and discussing.

• Adaptive Functions of Eating Disorder Behaviors

• Control and Helplessness

• Family and Personal History Regarding Food and Weight

• Ability to Nurture and Be Nurtured

• Perfectionism, Competition, and Loneliness

• Anger and Assertiveness

• Body Image and the Need to Develop an Essential, Not Ornamental, Self

• Intimacy and Sexuality Spirituality

• Separation and Individuation

• The Importance of Sex Roles

• Women's Conflict around Achievement

• The Power of Language to Shape Thought Patterns and Sub-sequent Actions

• Trust and Mistrust

• Risk Taking

To end this chapter, here are some excerpts taken from journal entries made by patients in group.

Group was hard tonight because everyone told me that I don't share enough and it is hard for them to know how I am feeling or what I am thinking. I told them that I just don't know myself. But now that I am home I realize that I do know but I don't feel comfortable sharing it. I have always had a hard time opening up to even one person, let alone a bunch of them together. Perhaps I will read this in group next week and this will be a way of beginning to share.

I hated sitting in group tonight. I just felt fat, fat, fat. And when Carolyn asked me how I felt all I could say was fat. I know fat is not supposed to be a feeling but that is what I felt. It's especially hard with the new girl, Heather. She is thinner than all of us, especially me. I bet others felt this too. I should ask them next week. This just reminds me that I will have to deal with other people and their thinness because there will always be someone thinner than me and anyway why should this matter so much.

I really felt for Karen today because two weeks ago, she was so excited about her "diet." I knew it wouldn't last for her and sure enough, there we were today, sitting there, listening to her tell us how she blew it. The diet didn't last. Now she's bingeing and throwing up again. I look at her and wonder what goes on in her mind. There's more to it than just being thin. She is so unsure of what she wants and who she should be. Some of the things she says just don't make sense to me, yet I have said them. Seeing her really makes me think about myself.

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I had a hard time today looking at Christy. She is so thin, it really made me feel a little sick to see how thin her legs are. She is a walking skeleton. I know we weigh the same, I wonder how they all see me?

Just knowing that everyone else in the group is rooting for me, not judging me but supporting me to get better, has made it so much easier.

I'm surprised at how defensive I get when someone asks a question or wants clarification about something I've said. Tonight the group members told me how hard it is for them to talk to me, especially to ask me anything because I act annoyed and defensive. I guess I always feel suspicious of people's motives and am always thinking I'm being attacked. That's how I felt in my family, exactly like that.

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