Group Therapies for the Treatment of Bulimia Nervosa
IN THIS ARTICLE
Eating disorders continue to increase in prevalence among adolescents, young men and women, as well as older adults, affecting nearly 5 million Americans each year (Reiss, 2002). Specifically, 1.1-4.2% of teenage girls will develop Bulimia Nervosa during their lifetime (NIMH, 2008), and it is estimated that 8 in 100 females of all ages will suffer from Bulimia at some point in their life (Bulimia Help, 2008). Group therapy can offer countless time-related, economical, and therapeutic advantages for the treatment of Bulimia Nervosa. This article aims to review the various group psychotherapy methods currently utilized, such as self-help, psychoeducational, psychodynamic, relational, CBT, and integrated/sequenced group therapies. Further, this article makes recommendations toward effective group psychotherapy approaches, and suggests directions for future research and practice regarding group therapies for the treatment of Bulimia Nervosa.
Photo: Courtney Emery ND-2
Eating Disorders: An Introduction
Disordered eating patterns and behaviors and eating pathologies are highly prevalent in today’s societies, particularly in the Western culture of the United States. In fact, eating disorders affect nearly 5 million Americans each year (Reiss, 2002). However, more recent reports indicate that eating disorders of all types are becoming more widespread throughout the world, with causes rooted in the influence of Western media and culture.
The only clinically recognized eating disorders, according to the Diagnostic and Statistical Manual of Mental Disorders IV (APA, 2000) are Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder, and Eating Disorder Not Otherwise Specified (NOS). The most common of these are Anorexia Nervosa and Bulimia Nervosa; however, the occurrence of Binge-Eating Disorder is also rising.
Eating disorders have historically been regarded as a predominantly female issue. It is estimated that 5-10% of adolescent girls, young women, and adult women currently suffer from some form of an eating disorder (Riess & Rutan, 1992). Additionally, in a females’ lifetime, an estimated 0.5–3.7% will suffer from Anorexia and 1.1–4.2% will develop Bulimia (National Institute of Mental Health; NIMH, 2008). Although it has been established that females are much more likely to develop one or more forms of eating pathologies, the National Institute of Mental Health (2008) reports an estimated 5–15% of the people who suffer from Anorexia or Bulimia and almost 35% who suffer from Binge-Eating Disorder are male. All types of eating disorders are physically and psychologically harmful to males and females alike, and many can be life-threatening.
Anorexia Nervosa is a condition characterized primarily by self-induced starvation. Anorexia is a serious illness with drastic physical and psychological ramifications, which commonly include: weight loss of 20–25% body mass, amenorrhea (loss of menstrual cycle), excessive exercise, distorted body image, obsession with food and eating, depression, anxiety, and strive for perfectionism (Kinoy, 1985; APA, 2000). Bulimia Nervosa is closely related to Anorexia, and shares many of the typical manifestations and perceptual distortions.
Bulimia is a prevalent disorder among many Americans, and is characterized primarily by recurrent episodes of binge eating (consuming large quantities of food during a single sitting) followed by some form of purging, such as self-induced vomiting, laxative or diuretic use or abuse, excessive exercise, and fasting (Kinoy, 1985). More physiological and psychological features of Bulimia include amenorrhea, swollen glands, electrolyte imbalances, low self-esteem, and distorted body image (Kinoy, 1985).
Within the past three decades, Bulimia has emerged more prominently as a widespread clinical problem that affects mainly females in their teens and twenties (McKisak & Waller, 1997). This disorder has been estimated to occur in around 1–3% of young adolescent girls and young adult women overall, and between 4–9% of college women (Levine & Mishna, 2007); furthermore, research estimates that almost 8 in 100 women will suffer from Bulimia at some point in her lifetime (Bulimia Help, 2008).
Recent reviews indicate that men may have been struggling with Bulimia more than originally thought in the 1980s (Bulimia Help, 2008); just as women who struggle with disordered eating behaviors suffer from shame, low self-esteem, and societal pressures to conform to an ideal body type, men are under similar pressures to utilize drastic measures to achieve their own societal ideal. Eating disorders, Bulimia in particular, are on the rise in the gay community (Bulimia Help, 2008), and more research needs to be conducted in order to find effective treatment programs for males with eating disorders.
Bulimia is considered a “disturbance in emotional growth and in the establishment of a sense of self and self-esteem” (Levine & Mishna, 2007, p. 169-170). Moreover, the importance and meaning of food and eating have been directly linked with the individual’s relationship to the self or others (Levine & Mishna, 2007). Since the beginning of its acknowledgment as an eating disorder in 1979/1980 (Levine & Mishna, 2007; Bulimia Help, 2008), researchers have attempted to find efficacious treatment programs to help women who suffer from Bulimia Nervosa. Researchers have also attempted to identify etiologies of Bulimia, and some have found genetic links, while others have investigated social and developmental causes. Bulimia is thought to be a “multidimensional problem, with physical, societal, relational, emotional, and cognitive origins and expression” (Laube, 1990, p. 172).
Because it is such a complex and multi-faceted disorder that greatly interferes with psychological functioning (Levine & Mishna, 2007; Openshaw, Waller, & Sperlinger, 2004), an amalgamation of treatment modalities have been researched and implemented in an attempt to, essentially, find a “cure” for Bulimia. The purpose of this essay is to review the last few decades of research surrounding group treatment for women and girls with Bulimia, identify the most effective group psychotherapy approaches, and to propose new therapeutic possibilities to pursue in order to establish longstanding psychotherapy effects within both male and female populations.
Group Therapy Approaches
Group therapy claims significant time-related, economical, and therapeutic advantages. In particular, group therapy offers a more cost-efficient method of treatment (McKisak & Waller, 1997; Hobbs, Birtchness, Harte, & Lacey, 1989) for any type of physical, emotional, or psychological distress. In addition to the reduced cost of group therapy, the group format provides members with a relatively quick way to receive treatment soon after admittance of their problem (Nevonen, Broberg, Lindstrom, & Levin, 1999).
Benefits of group therapy for all types of issues include: decrease in sense of isolation or alienation and maintenance of individuality and independence (Levine & Mishna, 2007; Laube, 1990). Group therapy has emerged not only as a favored treatment modality for numerous types of physical, psychological, and emotional issues, but also as a choice treatment for individuals with Bulimia (Levine & Mishna, 2007; Riess & Rutman, 1992; Hobbs, Birtchnell, Harte, & Lacey, 1989).
In previous research, reports indicated that Bulimia can be effectively treated by group therapies of various orientations, but it was unclear as to which elements of those group therapies were contributing most to the recovery process (Hobbs et al., 1989). More recently, research has focused on which treatment models are providing the most effective short- and long-term improvements for individuals with Bulimia, and what features of the group therapy models are the most advantageous.
Regarding eating disorders and Bulimia in particular, group therapy in general provides a safe environment conducive to self-disclosure and honest discussions regarding the individuals’ struggle with this secretive disorder (Riess & Rutan, 1992). Group formats offer information regarding, and tasks relating to, nutrition, dangers of dieting, addictive, or restrictive behaviors, distorted thoughts, body image disturbance, relationship styles, stress, patterns of emotions, coping skills, and relapse prevention (Laube, 1990).
Group psychotherapy offers an opportunity for members to share similar experiences with one another and to test the unrealistic attitudes, beliefs, and expectations that accompany Bulimia (Nevonen et al., 1999). Due to the high prevalence of eating disorders and the significant attention and interest these illnesses have received from researchers in countless fields, several promising treatment programs have emerged (Riess & Rutman, 1992); no single therapy has been shown to be universally effective.
Various group therapies have theoretical bases and/or empirical support, with evidence of effectiveness at a general level (McKisak & Waller, 1997); however, only when exploring the numerous methods of group therapy does it appear evident which types of group therapies are more effective in the long-term treatment of Bulimia. This is not to say that under-researched types of group therapy are ineffective; rather, many are simply underrepresented in empirical studies.
Group therapy for Bulimia has ranged from short-term to open-ended, and many include some or all elements of theoretically established individual psychotherapy approaches. The common types of group therapies or theories adapted and implemented for individuals with Bulimia include: self-help (or guided self-help), self-psychological, psychoeducational, psychodynamic, relational, feminist, supportive, interpersonal, cognitive-behavioral, integrated, or sequenced (Levine & Mishna, 2007; Openshaw et al., 2004; Tantillo, 1998; McKisak & Waller, 1997; Riess & Rutan, 1992; Laube, 1990; Hobbs et al., 1989; Kinoy, 1985). After some review of these types of group therapies, it will be critical to analyze their efficacy and draw potential conclusions regarding future directions for group therapy research and implementation.
A self-help approach developed by the Anorexia/Bulimia Association (Kinoy, 1985) describes the theoretical base for the model as well as the specific elements that make up this approach. This self-help model aims to provide an atmosphere conducive to building trust by utilizing one non-professional co-leader who has recovered from Anorexia or Bulimia in conjunction with a professional co-leader (Kinoy, 1985).
This allows the members to connect with an individual who is further along in the recovery process, as well as with a professional who offers specific information regarding the illness or provides additional resources to explore. In this instance, self-help groups are intended as a supplement to medical and individual psychological treatment (Kinoy, 1985); however, some self-help groups are run locally as chapters of a larger organization, such as National Eating Disorders Association, or are strictly supportive in nature.
The aim of all self-help groups is for the member to become an introspective, self-searching individual by slowly decreasing the isolation each individual may feel (Kinoy, 1985) through interaction with others who have experienced similar issues (Laube, 1990). Self-help groups are a way for those struggling with this disorder to take responsibility for themselves while being role models for other members in various stages of Bulimia.
Psychoeducational methods to group therapy offer scientifically supported information regarding the etiology, effects, and potential course of Bulimia, in addition to supplemental information concerning social and societal factors, nutrition information, and the physiological effects and dangers of the disorder (Levine & Mishna, 2007). Psychoeducational approaches are typically used as a supplement to either individual or group therapy, and may be integrated into various forms of treatment.
Some studies have been conducted on the effectiveness of psychoeducational groups for Bulimia, and successful results have been reported (Riess & Rutan, 1992); however, the lack of long-term follow-up makes it difficult to determine what lasting the lasting effects on symptomology reduction might be.
Therapists with a psychodynamic orientation encourage group treatment because they believe it helps members “re-experience and examine problems in relating to others” (Laube, 1990, p.170). It is a holding environment that fosters nurturing, soothing, and regulation of tension (Levine & Mishna, 2007). Through processes of “validation, self-empathy, mutuality, and empowerment” (Levine & Mishna, 2007, p.173), psychodynamic psychotherapy groups for Bulimia encourage members to deal honestly each other and attempt the same experiences outside the group relationship (Laube, 1990).
It is often difficult to ascertain the effectiveness of psychodynamic groups; due to the open-ended and long-term nature of the therapy, individuals may be exposed to a variety of behavioral, cognitive, self-help, psychoeducational, or several other techniques or theories (Riess & Rutan, 1992). This is one reason it is difficult to establish empirical support for psychodynamic group psychotherapy.
Relational theory states that the construction of the self (for women) occurs through emotional and psychological connection and mutual sharing with others (Tantillo, 1998). A relational understanding of Bulimia, then, asserts that the disturbance in a woman’s relationship with food and eating can be viewed within a large framework; specifically, girls with unmet needs of mutual empathy and empowerment in relationships may be more prone to bulimia because of the disparities they encounter at this developmental stage (Tantillo, 1998).
On one hand, Tantillo (1998) argues that women are encouraged to value competition individualism, and autonomy and are asked to compete with one another through control of their bodies. On the other hand, doing so may result in loss of friendships and relationships with others, thereby damaging their relationship with their self and transferring relationship issues to food and eating. Tantillo proposed relational therapy as an approach to Bulimia because of the unique elements of relationship issues within this disorder.
In a review of three articles empirically supporting group therapy for women with multiple psychological diagnoses, Tantillo attempted to apply the theory behind the relational approach to women with Bulimia. In this approach, the relational therapy group leader needs to emphasize and promote four healing factors (Tantillo, 1998): validation, self-empathy, mutuality, and empowerment. Through the use of case vignettes, Tantillo offered situations encountered in group therapy with individuals struggling with Bulimia, and applied the relational therapy to the case. Because this was not a research study, empirical support for relational group therapy is still unknown.
The goal of CBT is to recognize and modify behaviors and thoughts that maintain bulimic symptoms while developing some personally effective coping mechanisms (Binford, Mussell, Crosby, Peterson, Crow, & Mitchell, 2005). CBT targets abnormal eating patterns and behaviors and addressed underlying distorted thoughts concerning food, body image, weight, and body shape (Nevonen & Broberg, 2006). The CBT approach is the most commonly researched therapy; it is a semi-structural, not open-ended (i.e. short-term), and measurable type of therapy, making it widely available for research studies. The efficacy of Cognitive-Behavioral Therapy for individuals with Bulimia Nervosa has been well-established in the individual context (Binford et al., 2005; Chen, et al., 2003; Nevonen & Broberg, 2006), but few research studies have examined if group CBT is as effective as individual CBT.
According to Openshaw et al. (2004), group CBT results have not been as impressive as individual CBT results, where the risk of relapse at follow-up is much higher for individuals in CBT groups in uncontrolled studies. Chen and colleagues (2003) investigated if group and individual CBT are clinically comparable. Although the study was not without limitations, Chen and colleagues found that both group CBT and individual CBT were effective in reducing the primary and secondary symptoms of Bulimia, and that binge eating and self-induced vomiting reduction or abstinence rates were comparable to previous studies regarding CBT. Openshaw et al. also found that people suffering from Bulimia can benefit from and respond well to group CBT format. Although their results were statistically significant, the researchers recognize that this may not translate to clinical significance. The results were similar to Chen and colleagues’, and improvements in bulimic and restrictive attitudes and behaviors were maintained at six-month follow-up. One of the major limitations is that long-term follow-up measures have not been explored.
Like Chen et al. (2003) and Openshaw et al. (2004), studies have shown significant reductions in binge behaviors and dietary restraint, as well as improvements in body image and/or attitudes toward weight and shape (Binford et al., 2005). However, results indicate that these improvements may not be maintained; for example, while one-half of the individuals are without bulimic symptoms at the end of therapy, only one-third to one-fourth are symptom-free at the six-month follow-up. Although this is still a great improvement for the individuals without bulimic symptoms or with a reduction of symptoms, further research needs to be conducted in order to determine how to maintain those critical gains at long-term follow-up. Nevonen and colleagues (1999) state, “we have a long way to go before we can consider that we have a satisfactory treatment model” (p. 18).Continued on Next Page »