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Page 1 of 3 Psychiatric Annals 20:7/July 1990
Group psychotherapy offers a unique format in which some of the more intractable features of bulimia nervosa are amenable to change.
The 1964 edition of "The Abnormal Personality" has little mention of eating disorders as we know them today. Anorexia nervosa and bulimia nervosa are subsumed under gastrointestinal disturbances, with the author stating:
Digestive and eliminative processes are subject to many kinds of disorder. There are disorders of appetite and eating: at one extreme stands bulimia, marked by inordinate appetite and excessive eating; at the other extreme, anorexia nervosa, a loss of appetite so exaggerated that it sometimes threatens life.
In a mere two decades, with the cultural sway toward slimness, eating disorders have become a major health problem. Eating disorders have become so prevalent that they are included in the DSM-III-R as discrete clinical phenomena.
Bulimia nervosa is a compulsive eating syndrome characterized by uncontrolled binges followed by self-induced vomiting, laxatives, or diuretic abuse. Ambivalence, dysphoria, and self-deprecating thoughts accompanied by an over-concern with slimness are yet other features of this disease. The vast majority of those afflicted with this disorder are young women between the ages of 14 and 42, with the majority falling in the adolescent and young adult age ranges. Currently, 8% of all females and 1% of males are diagnosed as bulimic, according to DSM-III-R criteria.2 The prevalence of the disorder under-scores the need to examine treatment successes critically and to continue to develop viable methods that combine the best of group, individual, and pharmacotherapy strategies. Although comparative studies have vet to demonstrate the superior efficacy of group psychotherapy, a considerable body of literature suggests many of the symptoms of the bulimic patient may be reduced through this modality.3
Group psychotherapy offers a unique format in which some of the more intractable features of bulimia nervosa are amenable to change. In particular, intense feelings of alienation and shame are reduced by sharing the secret of the binge-purge cycle. Perfectionism, unrealistic expectations, and negative beliefs about the body and the self may be challenged by other group members. Identification of feelings may take place in an atmosphere conducive to interpersonal learning.3-18 Moreover, in a medium in which trust develops, the myth of personal incompetence-the belief that an individual has no value apart from her slimness-can be challenged.
Because the group symbolically represents the nuclear family, childhood traumas can be reworked and resolved in the group setting. As such, group psychotherapy offers a viable modality for patient recovery.
LONG-TERM VERSUS SHORT-TERM GROUP PSYCHOTHERAPY
For the specific issues of the eating-disordered patient, a long-term, open-ended psychotherapy group may represent the most effective form of treatment. While a short-term group may deal well with symptom management and support, the long-term group provides fairly predictable stages of development in which core dysfunctional beliefs may begin to emerge safely. The long-term group allows for the reestablishment of trust that has somehow been shattered in the patients' formative years. As patients begin to interact, doubts, misperceptions, and fear of intimate contact emerge. Honest feedback can be offered in a way that is new and different for the patient who has been accustomed to criticism. Within the "in vivo"5 culture of the group, the total personality and modus operandi of each individual can be understood, analyzed, and corrected.
Intense feelings of alienation and shame are reduced by sharing the secret of the binge-purge cycle.
The consistency and stability of a long-term group allows for the development of group cohesiveness, which provides a foundation for the maturation of trust-a crucial factor in the recovery of the eating-disordered patient. Members may begin to shift the focus of their concern from symptoms to the sharing of their true selves. It is particularly within the context of long-term group treatment that the eating-disordered patient develops her social skills and tentatively ventures forth into interpersonal intimacy.
BULIMIC PROFILE
In understanding the impact of group psychotherapy on the bulimic patient, a representative personality profile, illustrated by the following vignette, is useful.
Vignette
Lauren, a woman in her mid-20s, has a 5-year history of bulimia. From a prominent family, her parents placed a high premium on appearance, conformity, and achievement. Lauren was an appealing, but chubby, child who was often nagged about weight by her intrusive mother. She recalls her preteen years as uneventful, although they were punctuated by several efforts at dieting. When she was 17, her parent's separated-a traumatic event. One year later, she left home to attend a highly competitive university. She did well as an undergraduate, but her confidence was shattered when her college boyfriend left her. At that time, she began binging and purging. She was able to go on to law school and graduated in good standing despite her illness.
Shortly thereafter, she presented for treatment: attractive, composed, and well groomed. Beneath her veneer of success lay crippling self-doubt - her slim body was her only proof of adequacy. She complained of loneliness and of being unable to form new relationships, particularly with men. To avoid pain, she avoided contact. Food became her intimate companion and purging a desperate attempt to feel in control of her life.
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