Applying Group Therapy to Eating Disorders
by Dr. Eleanor Kurtus (revised 14 Februrary 2012)
Group therapy is one component in the overall treatment of eating disorders. In some programs, group therapy is the only modality used, while in others, such as residential settings, it is an adjunct treatment used with other techniques.
Questions you may have include:
- What are the types of group therapy used to treat eating disorders?
- How are these therapies applied?
- How does the success rate compare with personalized therapy?
This lesson will answer those questions. Mental Health Disclaimer
Types of Group Therapy
Various types of group therapy are used with eating disorder patients. Each type of group has a different orientation with a different focus, activities, and format. The theoretical orientation of the therapist drives the orientation of the group. The types described in the eating disorders literature include cognitive/behavioral, behavioral, psychoeducational, and psychodynamic/interpersonal. Additionally, there are addiction-oriented and self-help groups, which are not traditional therapy groups. This section describes each type of group with its focus and format.
Cognitive/Behavioral Therapy Groups
Cognitive/Behavioral Therapy groups use strategic therapy with the goal of modifying underlying schemata in order to break the self-perpetuating cycle of dieting, bingeing, and purging (ref. 1). A patient learns to monitor her thinking and beliefs about food, body shape, and weight. The therapist teaches how to collect data and examine it between the therapy meetings.
At the meetings, the therapist guides the patient to recognize the connection between her beliefs and their behavioral consequences. The therapist also facilitates deeper discussion related to maladaptive body image and self-esteem concepts. Behavioral methods are taught, which include self-monitoring, meal planning, stimulus control, and problem solving.
Behavioral Therapy Groups
With Behavioral Therapy groups, the focus is on identification of behavior patterns and developing strategies for behavior change. Disturbed eating symptoms are analyzed and patients are taught techniques such as self-monitoring, relaxation, and nutritional management.
Behavioral Therapy is a “dismantled version of Cognitive/Behavioral Therapy, consisting solely of those behavioral procedures directed at normalizing eating” (ref. 2). Behavioral Therapy does not attempt cognitive restructuring.
Psychodynamic/Interpersonal Therapy Groups
The focus in the Psychodynamic/Interpersonal Therapy groups is less on the symptoms of eating, weight, and physical health, and more on interpersonal relationships. Treatment for the physical issues through behavioral, cognitive, or educational therapy may be used in conjunction with, or preceding, this group work.
In the Psychodynamic/Interpersonal Therapy group, members work through internal and interpersonal difficulties. These groups are particularly well suited to resolving difficulties with basic self-control functions such as tension, self-esteem, and a sense of stability (ref. 3).
The group is unstructured and works in the “here and now” format. Members interact in a social microcosm in which the individual eventually begins to exhibit a maladaptive mode of relating to others. The goal is to foster corrective emotional experiences, so that the individual may improve by addressing issues dealing with self-regulation, identity, and personal empowerment.
Patients with eating disorders are generally well defended in regard to interpersonal problems. Because many tend to over-accomodate in relationships, are hypersensitive to criticism and rejection, and have difficulty identifying and expressing affect, the therapist generally spends more active time and work with an eating disorders group than most other psychotherapy groups (ref. 3).
Psychoeducational meetings are highly structured. Each meeting is organized around a theme or number of topics. The leader presents information and advice. There may be a question and answer session or discussion period, but participants are not encouraged to self-disclose.
The goal of a psychoeducational group is to help achieve biological and psychological stability by emphasizing interpersonal and emotional issues, assertiveness, and coping styles (ref. 6). This type of group consists of group sessions, plus assigned reading and homework. Topics covered in such a program are:
- Education and overview
- Eating as coping; developing alternative coping strategies
- Self-esteem, perfectionism, and depression
- Anger and assertiveness
- Cultural expectations of thinness
- Enhancing body image
- Progress review and goal setting
After participating in a psychoeducational group, an individual may continue on in individual or group therapy, depending on the severity of the problem.
Addiction-Oriented and Self-Help Groups
An addiction-oriented group, such as Overeaters Anonymous, is non-professionally run; members take turns facilitating meetings. These groups view eating disorders as variants of substance abuse and propose the existence of an “addictive personality” (ref. 4).
These groups are not widely advocated by professional therapists, because they ignore the underlying psychopathology of eating disorders, which extends beyond mere abstinence and dieting. It is concluded that the promotion of abstinence encourages dieting. This in turn undermines the therapeutic wisdom for treating eating disorders and does not address the core clinical issues, such as the psychobiological connection between dieting and eating disorders, body image, and coping strategies.
In self-help groups, patients exchange information and experience, while providing acceptance and emotional support. These groups are facilitated by nonprofessionals and may be used as adjuncts to professional treatments.
Success Rate for Eating Disorder Treatment
In this section, success rates for three types of individual therapy used with eating disorders are presented, followed by results from studies of group therapy. Reviewing the individual therapy results is worthwhile for possible application to group therapy methods.
Studies demonstrate that Cognitive/Behavioral Therapy and Psychodynamic/Interpersonal Therapy are comparable in results. On the other hand, Behavioral Therapy seems inferior to Cognitive/Behavioral Therapy, which is rapid in achieving change (ref. 7). With Psychodynamic/Interpersonal Therapy, the changes took longer to achieve full effect, but after one year were comparable to Cognitive/Behavioral Therapy.
Comparison of rates
Behavioral Therapy had an immediate, but short-lived effect. In a 1-year follow-up, 48% of the Behavioral Therapy group dropped out or were withdrawn because of lack of improvement. The dropout rate for Cognitive/Behavioral Therapy was 20%, but the dropouts maintained their improvement and did not deteriorate. At a 5-year follow-up, the abstinence rate from binge eating and purging was:
- Cognitive/Behavioral Therapy 44%
- Psychodynamic/Interpersonal Therapy 52%
- Behavioral Therapy 18%
A study of Cognitive/Behavioral Therapy of group therapy, indicated a higher success rate. At an 18-month follow-up, 68% of the patients had ceased bingeing and purging, with another 22% showing improvement (ref. 6).
In controlled evaluation
In a controlled evaluation of the effectiveness of psychoeducation group therapy, greater improvement was observed in the treated group as compared to the control group. Although the improvement manifested in self-esteem, eating behavior, body image, and depression, many patients were still bingeing and purging at a reduced rate at the end of the treatment, with some showing no change at all (ref. 6).
In a comparison of the effectiveness of group therapy versus individual therapy for obese patients, both types resulted in significant weight reduction. However, group therapy resulted in greater weight loss than individual therapy, even for patients who, at the outset, stated a preference for individual therapy (ref. 5).
Eleanor Kurtus has a Doctorate in Psychology, as well as a B.S. degree in Physics, a Masters of Business Administration (MBA), and Masters Degree in Counseling.
She can be reached at firstname.lastname@example.org.
Resources and References
The following are resources on this subject.
1. Davis, R. & Olmsted, M. (1992). Cognitive-behavioral group treatment for bulimia nervosa: Integrating psychoeducation and psychotherapy. In H. Harper-Giuffre & K.R. MacKenzie (Eds.), Group psychotherapy for eating disorders. Washington, DC: American Psychiatric Press.
2. Fairburn, C. (1997). Interpersonal psychotherapy for bulimia nervosa. In D.M. Garner & P.E. Garfinkel (Eds.), Handbook of treatment for eating disorders. New York: The Guilford Press.
3. Harper-Giuffre, H. & MacKenzie, K.R. (1992). Interpersonal group psychotherapy. In H. Harper-Giuffre & K.R. MacKenzie (Eds.), Group psychotherapy for eating disorders. Washington, DC: American Psychiatric Press.
4. Polivy, J. & Federoff, I. (1997). Group psychotherapy. In D.M. Garner & P.E. Garfinkel (Eds.), Handbook of treatment for eating disorders. New York: The Guilford Press.
5. Renjilian, D., Nezu, A., Shermer, R., Perri, M., McKelvey, W., & Anton, S. (2001). Individual versus group therapy for obesity. Journal of Consulting and Clinical Psychology, 69(4): 717-721. Retrieved July 28, 2002, from http://FirstSearch.oclc.org.
6. Schlundt, D.G. & Johnson, W.G. (1990). Eating disorders: Assessment and treatment. Boston: Allyn and Bacon.
7. Wilson, G.T., Fairburn, C.G., & Agras, W.S. (1997). Cognitive-behavioral therapy for bulimia nervosa. In D.M. Garner & P.E. Garfinkel (Eds.), Handbook of treatment for eating disorders. New York: The Guilford Press.
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