Women such as Lauren enter treatment possessed by an ego-alien compulsion. Isolated by their symptoms, they join together in group therapy to share, support, and enrich each other in a way different from any other previous experience. This point was illustrated when one patient asked another to describe a binge episode. As the patient described her odyssey from one restaurant to the next, the first patient admitted, "I thought I was the only person in the world who did that." For the bulimic patient, this universality of experience may exist only in the group.

Instillation of hope, interpersonal learning, and identification are among the most important therapeutic factors operative in the change process.⁴ When an experienced patient states to the neophyte patient, "I was once where you are now," the experienced patient becomes, at once, guide, inspiration and teacher. The following case studies illustrate this.

Case 1

Melody, an aging debutante in her 50s, was married with one small daughter. She presented for treatment with the complaint that she 'eats for three." She spent the major portion of her life worrying about her body size and the appearances of her home and child. Her activities revolved around exercise, charitable functions, and teas. She complained of dysphoria and free-floating anxiety bordering on panic.

In the group, she painfully described how badly she felt inside. She believed her life would he perfect if only she could lose 20 pounds. She had great difficulty understanding that the next bite of food would not magically obliterate the bad feelings and that fixing the outside would not alter the inner emptiness. She continued to focus on externals until one member gently confronted her, "We've heard a lot about your body, but we've not heard anything about your mind." The group accurately identified that her hunger was for a feeling of value. She painfully confessed her belief in her personal incompetence that she couldn't be anything but slim and beautiful. Her self-doubts were expressed in the following poem:

I am no good
I have no brain
Anything J achieve is by mistake
Therefore secretly
I VOMIT my achievements
I live through my body
My body is my only worth
No wonder I have so many
problems.

The group challenged this myth based on her active and intelligent participation with them. Melody became an important and respected group member. As the feeling of incompetence gave way to a more solid sense of self, she was transformed into a person with talents and ideas She helped the neophyte members work through their own feelings of incompetence and became a role model with whom others identified. At the time she left the group, she planned to return to school to pursue a graduate degree in design a sublimation of her concern with externals.

According to Yalom,4 the group recapitulates the nuclear family in ways that could never be accomplished in individual treatment precisely because the group feels like a family. Unconsciously, members take on the same role in the group that they assumed in their family-of-origin. The pathologic behavior is reactivated and reworked when the therapist and the patients, who symbolically represent the parents and siblings, foster the resolution of unconscious conflicts. Dysfunctional communication and pathologic behaviors can be identified; new behaviors can be practiced, and change can occur as the patient undergoes a corrective emotional experience. The following case illustrates this point.

Case 2

Nancy was a 42-year-old white married female who sought treatment for bulimia. Her parents died in a car accident when she was 6. Nancy was reared somewhat resentfully by her oldest brother and his wife. Despite the fact that she was physically cared for, her presence was barely tolerated. Sensing this reaction, she tried to be the nicest little girl in the world although she never felt loved.

Instillation of hope, interpersonal learning, and identification are among the most important therapeutic factors operative in the change process.

Nancy entered a stable and cohesive group 6 months after its inception. Although the group was prepared for a new member, they were not prepared for Nancy. During her first session in the group, Nancy began talking in a singsong fashion about her eating, her early life experiences, and then, tangentially, her philosophies. During the second session she continued to drone on. The experienced members of the group shifted uncomfortably until the leader interrupted Nancy's monologue to comment on the discomfort in the room. Annie a warm and verbal schoolteacher turned to Nancy. You know, you're acting like a 10 year old kid who doesn't know what's going on and who's trying to get the attention of the adults in the family by making nice. Maybe this is how you've coped since your parents died, but you don't have to make nice to be accepted here. We accept you because you, like me, have an eating disorder and you, like me, are in pain. That's enough."

Nancy was shaken by the gentle but constructive confrontation and threatened never to return to the group. In the next meeting, the therapist and members were able to help her process this valuable information. She was able to understand that being the "youngest person in the "family-group" had triggered regression, reactivating feelings of the frightened, abandoned child As she worked through these feelings Nancy came to acknowledge that binging had warded off her sadness for many years.