February 2010
The Use of Group Therapy in the Treatment of Eating Disorders
Kristin Lore, LCSW
Director, Cedar Associates Mount Kisco
Irvin Yalom, an expert in group psychotherapy writes about the instillation and maintenance of hope, (Yalom, 2005). Studies have shown a high expectation of help before therapy is significantly correlated with a positive outcome. Yalom further states that group therapy benefits from a source of hope that is unique to the group format. Following a group many will talk about how helpful it was for them to observe the improvement of others.
The group setting is also a powerful modality in combating cognitive distortions regarding perfectionism and negative beliefs about food, weight, body and self. The challenging of these beliefs by other group members is particularly conducive to interpersonal learning, (Asner, 2008). In a group in which trust develops, the feelings of interpersonal ineffectiveness and the belief that one’s value is attached to one’s thinness can be challenged.
Because the therapy group itself symbolically represents a family, childhood traumas and negative experiences can be resolved. While this occurs in individual therapy as well, the group offers a greater variety of possibilities to repeat relational conflict. As with individual therapy it is not the reliving of familial conflict but rather the corrective reliving that leads to resolution. Roles within the group must be constantly explored and challenged as well as the testing of new behavior. Working out problems in the group with the therapist and other group members is also working through earlier familial conflict, (Yalom, 2005).
Group psychotherapy was often though of as long-term, psychodynamic and open-ended. Still, many think of these groups as the most effective in developing the trust needed to move past symptoms and to share one’s true self and to develop social skills that moves closer to interpersonal intimacy. In this setting being nurtured and reciprocally being able to nurture others, the patient connects with his/her own sense of competence and the competence of others, (Asner, 2008).
In the past decade more attention has been given to cognitive-behavioral psychotherapy groups. These groups focus on symptom management by connecting beliefs with behavioral consequences. These groups have been particularly helpful with bulimic patients by targeting thoughts that can trigger binge eating. They also focus on learning coping skills to decrease the likelihood that stressful situations or negative thoughts will lead to a binge.
In addition to psychodynamic and cognitive-behavioral groups there are psycho educational and expressive therapy groups that provide effective treatment for eating disorder patients. Psycho educational groups tend to be structured and centered on a theme or topic. The therapist generally gives information and discussion ensues. These are not self-disclosing groups and thus are more limited in their scope. Expressive therapies such as art therapy and movement therapy can be helpful to those who struggle to express themselves verbally.
A group specific to eating disorder treatment is meal support therapy. Generally this refers to a group of eating disorder patients eating a meal with a nutritionist and then processing the feelings following the meal. Meal support can work by normalizing eating, creating a socializing, less stressful meal time and using the time after the meal to work through the feelings that came up while eating.
In summary, group psychotherapy is an extremely effective modality in the treatment of eating disorders and needs to be considered by therapists and patients alike to ameliorate symptoms and to work through the pathology underlying the disorder.
“A persuasive body of outcome research has demonstrated unequivocally that group therapy is a highly effective form of psychotherapy and that it is at least equal to individual psychotherapy in its power to provide meaningful benefit,” (Yalom, 2005).
While most clinicians agree that individual psychotherapy is the cornerstone of eating disorder treatment, it is the relevance of group psychotherapy that will be the focus of this article. From the 1980’s until the present there has been extensive research on epidemiology, etiology and treatment considerations for those with eating disorders. It is widely accepted that the etiology of eating disorders is multifaceted with psychological, socio-cultural and biological forces converging. Accordingly, treatment must also be multidimensional addressing the individual needs of one seeking treatment. Commonly an individual will receive a combination of individual therapy along with nutrition therapy and at times pharmacotherapy. Group therapy is often less a part of the treatment unless one is in an inpatient, day treatment or intensive outpatient setting. The importance of the group setting as a powerful adjunct to eating disorder treatment will be explored. Additionally, specific types of groups and various theoretical approaches will be discussed.
One suffering from an eating disorder often keeps it a secret from family and friends. As one’s weight plummets with anorexia, it is more difficult to keep it secret. However, as this occurs the person will tend to isolate and withdraw from social interaction, thereby feeling alone. Many times those with bulimia are able to maintain a normal weight and thus the condition can remain a secret. Further, bulimic patients are affected by the notion that others will look at their behavior with disgust, increasing the shame they feel. Many patients describe the lack of understanding they feel society has with regard to eating disorders. The misguided thoughts are that they are diets that have gone wrong or vanity or attention-seeking behavior rather than serious psychological disorders. This perpetuates the isolation and withdrawal from society.
One of the most effective aspects of a group setting is providing the feeling to patients that they are not alone. This is a powerful force and has been described as a “relief” by many who feel that “nobody understands unless they are dealing with it.” The realization that one is not unique in his/her suffering allows for deeper discussion of taboo subjects. The group provides validation that is different and often more powerful than any other therapy.