Bulimia Nervosa: Healing Through Group Work
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Bulimia Nervosa: Healing Through Group Work

The purpose of this article is to explain a group designed for helping women suffering from bulimia nervosa. The group consists of four sessions and includes the following topics: Introduction and personalized therapy contracts, developing tactics for overcoming bulimia nervosa, Draw-A-Person (DAP) test created by Machover (1949), and meal creation. Also, this article provides information about marketing and screening, cognitive-behavioral theory, informed consent, outcome questionnaire, and problem solving techniques for group practice.

Introduction and Rationale

The type of group proposed is for women suffering from bulimia nervosa (BN).  BN is described as uncontrollably binging on food and then purging the food from the body by using laxatives, diuretics, puking, fasting, or exercise.  The reason for the group formation is to help women overcome this disorder by gaining greater self-worth, confidence, and self-respect (Blechert, Ansorge, Beckmann, and Tuschen-Caffier, 2011).

All clinicians who work personally with anyone suffering from BN are trained in cognitive-behavioral therapy (Latzer, Peretz, and Kreutzer, 2008), and they hold such degrees as psychiatrist and licensed professional counselor (Schaffner and Buchanan, 2008). Additionally, research supports the valuable effectiveness of support groups for women suffering from bulimia nervosa.  This is because women suffering from BN are educated in support groups about the character of BN, as well as healthy coping techniques (Gladding, 2008).

Previously developed needs statements provide that BN patients need help with BN actions- such as puking and using laxatives and diuretics- as well as the supplementary feelings and moods, by using such therapies as the cognitive-behavioral model.  Other needs orient a dynamic model to treat BN patients, and this model seeks to uncover the core of emotional trauma that drives the bulimic (Latzer et al., 2008). Each is designed to meet the needs of the bulimic, in order to promote improved health.

Group treatment of BN in women can help lower the 1.5% lifetime prevalence of BN among women, which can span from 1.7 to 8 years total (Guez, Lev-Wiesel, Valetsky, Sztul, Pener, 2010).  Another study providing similar statistics states that there is a 1% BN occurrence among women in the United States and Western Europe (Shapiro et al., 2007).  Overall, support groups help women suffering from BN (Guez et al., 2010).

Sessions Outline x4

Session 1: Introductions to the Group and Creating Personalized Therapy Contracts

I. Six Goals are included in this first meeting.

A. One goal includes completing a successful introduction. (30 minutes)

  1. Each woman introduces herself and explains her difficulties with eating, especially pertaining to her past.
  2. Discuss Requirements for this group (12 minutes)
  3. Maintaining a diary of foods consumed is required.
    1. All members must keep a weight within normal range.
    2. Each woman should eat nutritiously balanced meals each day.
    3. Members are required to come to each group meeting.
    4. Overcome bulimia by taking action (2 minutes)
      1. Actions include attending all group meetings and following through with activities.
      2. Describe the diary for food (15 minutes)

1. The diary must remain with each woman at all times.

  1. The purpose of this diary is for each member to identify eating rituals, as well as relationships between binging and bulimic actions compared to an emotional state.
    1. The diary must include the following about consumed food: the quantity, type, location, if anyone else was with the member, time of day, details about any desire to overindulge and purge, and details about acting on this desire.
    2. The diary must also include any unusual or exciting occurrences.
    3. Members must include when they have exercised and the time span.
    4. Lastly, the diary should include details about each woman’s emotions and moods.
    5. Members should understand that writing in the diary will be discussed at each meeting.
    6. Benefits of keeping a diary (11 minutes)
      1. Each member will realize any core and motivating reasons about hunger.
    7. Binging occurs less often when a diary is kept (Latzer et al., 2008).
    8. Members “begin to understand that their eating, binging, purging behaviors are in reaction to their emotions” (Latzer et al., 2008, p. 378).
    9. Closing (20 minutes)
      1. Members can each talk to the group about how they feel about this group (Jacobs, Masson, Harvill, 2009).

II. Supplies Needed

  1. Each woman must bring a diary and pen, which they were told to bring during the interview.

III. Room set up

  1. The room set up is in a circle format, which promotes fairness in significance and authority. The purpose of this arrangement is for each member to have a complete and open view to other members (Gladding, 2008).

Session 2: How to develop tactics to overcome BN

I. Three primary goals are included in this session.

  1. The first goal is to gain greater self-worth, confidence, and self-respect. (15 minutes)
    1. Each woman can participate in an opening group discussion by sharing key details in her diary from the past week
    2. Discuss realistic approaches to cope with BN symptoms using the cognitive-behavioral theory
      1. Talk about this topic with the women. Women battling BN should be candid and audibly talk about their feelings instead of purging to show these emotions. For example, what feelings are they experiencing that influence purging? (12 minutes)
        1. Discuss this skill with the group: diversion and calming techniques utilized in place of binging and purging (Schaffner and Buchanan, 2008).  For example, what is something that calms or is another activity such as jogging (Binford et al., 2005)? (12 minutes)
        2. Openly converse about this thought process with the group.  Talk with the members about consuming food sensibly instead of binging (Schaffner and Buchanan, 2008).  Can members imagine themselves not binging and puking and instead eating sensibly (Binford et al., 2005)? (12 minutes)
        3. Understand and practice stable and healthy thought patterns about the consumption of food in place of food restriction (Schaffner and Buchanan, 2008).  Can members contact a friend to talk through such situations (Binford et al., 2005)? (12 minutes)
        4. Talk with the group about how each woman handles stress.  Does this trigger bulimic episodes for them?  If so, how can the women handle stressful situations and not avoid stressful situations (Schaffner and Buchanan, 2008; Binford et al., 2005)? (12 minutes)
        5. Closing (15 minutes)
      2.  Due to discussing many coping techniques today, will anyone make any changes or actions prior to session 3 (Jacobs et al., 2009)?
      3. Supplies Needed

A. Each woman must bring her diary.

III. Room Set up

A. The room set up will be the same as session 1, which is a circle format. This arrangement also promotes fairness in significance and authority.  The purpose of this is for each member to have a complete and open view to other members (Gladding, 2008).

Session 3: Draw-A-Person (DAP) test created by Machover (1949)

  1. Three goals are included in this session.
    1. The first goal is to open the group with an activity. (ten minutes)
      1. Group members can discuss any thoughts to what was discussed during last week’s session (Jacobs et al., 2009)
      2. The next goal for this session is for each woman to gain insight into her view of her own body weight and shape. (10 minutes)
      3.  Each will gain this insight by drawing herself through the Draw-A-Person (DAP) test created by Machover (1949).  This exercise was designed to identify women who have an eating disorder, and the exercise provides each woman with the chance to relate to their own body.  Directions include for each woman to draw the body image figure of herself, and no further directions are provided.  The choice of how each woman chooses to draw her body is her decision.  In this case, the body image figure that she draws and whom she wishes to look like releases “the issue of conscious and unconscious conflicts about one’s body image” (Guez et al., 2010, p. 411). 
        1. After drawing the figures, the leader will initiate a voluntary discussion where each of the women can describe her figure. 

1. Each member can make an assessment of body weight and form (20 minutes)

2. Members can provide reasons for the importance of body image to women (15 minutes)

  1. Members can provide reasons for discontentment about their body image (15 minutes)
  2. The leader should ask members to specifically assess the body shape silhouette, image size, neck, feet and legs, sexual parts of the drawing as well as the thighs which represent femininity and could trigger a struggle, and the mouth (Guez et al., 2010). (15 minutes)
  3. Homework Goal for Session 4 (5 minutes)
    1. Each woman must write about her feelings, moods, and emotions experienced  throughout her participation in the group for the past three weeks.  She must include how she has acquired confidence and self-control for BN (Latzer et al., 2008).  She will briefly discuss her writing at the next meeting.

2. Each member must also bring her own ingredients for a meal she would like to  prepare (Schaffner and Buchanan, 2008) at the next meeting.

II. Supplies Needed

A. Blank sheet of paper, sized A4

B. 1 pencil for each participant

III. Room Set up

A. The set up will be in a circle arrangement, and the room will be quiet and comfortable.  This arrangement promotes fairness in significance and authority.  The purpose of this format is for each member to have a complete and open view to other members (Gladding, 2008)

Session 4: Creating a meal

I. There are five goals which focus on establishing greater self-worth, confidence, and self-respect.  Each of these goals is tied into one major exercise.  Group members “bring their own meals from home, prepare them at the center, and eat in groups led by a therapist who provides educational and emotional support” (Schaffner and Buchanan, 2008).

  1. An introduction opens the group. (10 minutes)
    1.  Each woman discusses key details in her diary from the past week.
    2. Each group member makes a meal at the facility (15 minutes)

1. Members should maintain awareness of personal emotions, including any feelings of anxiety while preparing the food.  Each woman should try to be confident.

C. Group members eat their meals together. (45 minutes)

            1. Group members should continue to maintain awareness of personal emotions, including any feelings of anxiety while eating.

2. The leader should be caring, reassuring, and provide help with any questions about emotions at this time. 

3. Identify both an appetite for food, as well as feeling full while eating a meal.

4. The group leader will bring with her a nutritious meal in order to show group members a healthy meal example.

5. Group members can talk about a balanced and healthy meal.

  1.  Identify any habitual eating patterns that are unhealthy.
  2.  Members can discuss any difficulties with their meal while eating together.

D. Closing activity terminates the group. (20 minutes)

  1. Each woman can discuss what she has learned from the group during the past four weeks.  She can use the paper she wrote, that was assigned in session 3, as a basis for sharing with the group her emotions, feelings, and personal outlook regarding BN (Latzer et al., 2008).

II. Supplies Needed:

  1. Since meals will be prepared on-site, each woman participant must bring the ingredients of a simple meal that can be put-together.  Each woman must also bring her written assignment that was mentioned in week 3.

III.Room Set up

B.Initially, each woman will make her meal at the facility (Schaffner and Buchanan, 2008).  After each woman makes her meal, everyone will join together in the circle arrangement, which was utilized in sessions 1 to 3. This arrangement promotes fairness in significance and authority.  The purpose of this format is for each member to have a complete and open view to other members (Gladding, 2008).

Marketing and Screening

The intended audience consists of women between the ages of twenty and thirty-five who are diagnosed with BN.  The leader will interview possible candidates to become group members, and the group will total approximately ten women.  The criteria for determining who should not be included in the group consist of the following. Women who seem immature and do not demonstrate the ability to add to group development could be excluded.  Such characteristics include women who are egocentric, aggressive, emotionally unstable, apathetic, unable to deal with nervousness, and who are reluctant to be open in the group. 

Also, women who fit the following description are not permitted in the group. The diagnosis of bulimia may occur with another axis-I psychiatric disorder.  These additional disorders could include depression and anxiety.  If any possible candidates have been diagnosed with bulimia nervosa and another axis-I disorder, these participants will not be included.  This is due to the comorbid state of two disorders occurring together.  All of these women who meet exclusion criteria may find personal counseling more advantageous compared to group support (Jacobs et al., 2009; Gladding, 2008).

Screening questions consist of the following:

  • Do you have any experience with groups?
  • What do you believe this group will be like?
  • What is your reason for wanting to join this group?
  • What benefits can you provide to this group?
  • How will you be benefitted by this group (Jacobs et al., 2009)?

Theory

The particular counseling theory that will be utilized is cognitive-behavioral theory.  This is because the cognitive-behavioral theory approach is considered most useful for treating people who are suffering from BN (Binford et al., 2005).  Cognitive-behavioral therapy is practiced when the practitioner uses a collective method to become aware of the client’s way of thinking.  Through this tactic, the counselor becomes aware of the client’s negative thoughts and convictions, such as those associated with BN, and replaces these views with positive and beneficial beliefs (Corey, Corey, Callanan, 2011); however, throughout this process it is vital that the client and practitioner develop a trusting relationship since this is fundamental for healing (Tan, 2003). 

The reason that replacing damaging thoughts with a constructive belief system is incredibly advantageous in BN and meets the goals of establishing positive self-image and self-esteem (Blechert et al., 2011), is because “how one thinks or behaves largely determines how one feels and functions and what one does indicates who one is” (Gladding, 2008, p. 417).  This means that the purging and succeeding measures taken to avoid weight gain in BN are the physical manifestations of negative beliefs such as damaged self-worth, lack of confidence, and little self-respect (Blechert et al., 2011).  The goal of overcoming BN and these damaging thoughts can be achieved when a counselor utilizes the cognitive-behavioral therapy and works with the client to change the negative thoughts to a positive belief system (Gladding, 2008).

Bulimia Nervosa Group Counseling Informed Consent Form

This consent form has been developed for the Women’s Bulimia Nervosa Support Group.

Member Responsibilities:

  • Members should demonstrate integrity, respect, openness, and a non-judgment (Jacobs et al., 2009).

Leader Responsibilities:

  • The leader should be respectful and receptive, responsible for planning group meetings, act as a facilitator, and show a non-judgmental attitude towards members (Corey et al., 2011).

Group Goals:

Members should have an increased understanding of BN and the effects of this disorder.  Members should also develop greater self-worth, confidence, and self-respect while obtaining a greater understanding of body image.  Each member should also improve their interpersonal communication (Guez et al., 2010).

Rationale for the organization of this group:

  • The hope is that each woman participant obtains a greater understanding and respect towards herself so that the strongholds of BN can be released.  The rationale of group therapy for BN holds that members become stronger by feeling belonging, recognizing commonality, experiencing real-life conditions, and commitment to one another for improvement (Jacobs et al., 2009)

Confidentiality:

  • Each group member can discuss thoughts that are on her mind (Gladding, 2008).  Everything discussed in the group must remain in the group.  Exceptions include if a member is suicidal or in danger of hurting a group or non-group member.  Additional exceptions include if someone in the group is abusing a senior person, someone who is disabled, or a minor child.  A serious threat against any third person whom the client intends to harm is an exception to confidentiality.  Lastly, information can be discussed outside of the group for supervisory reasons (Clinton and Ohlschlager, 2002).

I agree with the above responsibilities and obligations of this group.

Group member signature__________________ Printed Name____________________

Group leader signature____________________ Printed Name____________________

Date_________________ (Gladding, 2008)

Lydia Vigna

M.A. Professional Counseling Student

Liberty University

Outcome

The following is a bulimia nervosa support group survey. Please circle each answer on a scale that ranges from 1 to 4, where “0=never, 1=rarely, 2=sometimes, 3= frequently” (Binford et al., 2005).

  1. Do you recognize any constructive and alternative actions that can replace purging behaviors? 0  1   2   3  
  2. Do you feel you have greater self-control regarding dietary restraint? 0  1   2   3 
  3. Are you experiencing greater self-respect towards your body shape? 0  1   2   3 
  4. Do you find your self-esteem improving?  0  1   2   3  
  5. Do you have greater restraint when deciding to purge or not to purge?  0  1   2   3 
  6. Does BN negatively affecting your self-confidence (Roberto, Grilo, Masheb, White, 2010)?     0  1  2  3 
  7. Is your drive for thinness decreasing?  0  1   2   3  
  8. Do you find that you are more content with your body?  0  1   2   3  
  9. Do you have greater awareness for the importance of nutrition to your body?  0  1   2   3  
  10. Do you believe that you are better able to manage stress?  0  1   2   3 
  11. Do you find that you have less of an urge to vomit?  0  1   2   3 
  12. Do you find your attitude improving about body image (Shapiro et al., 2007)?  0  1   2   3  
  13. Do you believe you have acceptable choices for overcoming binge eating?  0  1   2   3
  14. Do you find your social and interpersonal skills improving? 0  1  2  3
  15. Have you found this group to be helpful to you in your life? 0  1  2  3 (Schaffner and Buchanan, 2008; Binford et al., 2005)

Problem-Solving

The Chronic Talker

         A chronic talker should be addressed in the following manner.  As with any group member who is posing a potential problem, it is key to first contemplate why a member is chronically talking and to not judge too early or too quickly; however, the earlier this issue is dealt with, the better off the chronic talker and other members.  Clearly, this member is focusing attention on herself and not on others.  The chronic talker has underlying anxiety that is causing the talking, and it is essential for the leader to know that the talking can cause others to become irritated.  To correct this behavior, the group leader along with members should communicate how this behavior can harm relationships.  Furthermore, the chronic talker could use the advice of other group members and the leader to discuss ways to improve interpersonal communication.  One way to deal with chronic talkers is the method of cutting off (Gladding, 2008).

The Silent Member

         If a member of the group is silent, it is important to first consider the reason for the quietness.  Is the silence merely a shield from underlying resentment?  On the other hand, is the silent member timid, reluctant, introverted, or simply leisurely in providing feedback?  One way to prompt conversation is to provide the silent member with the chance to answer questions.  It is important for the group leader to try to get the silent member to talk, because the silent member will most likely obtain greater benefits from the group by participating.  Moreover, it is fundamental for the group leader to encourage input; otherwise this participant’s actions could negatively impact the group.  If the group leader accepts the quiet member, yet generates chances for the member to participate, this could mend any adverse effects on the group (Gladding, 2008).

The Member Who Attacks Another in the Group

         Often group members attack others in the group, because they are indignant.  This is important for a leader to understand when addressing this type of group problem.  These members carry unsettled issues concentrated on manipulation and power into the group.  It is important that the leader maintains control and influence over the group and not allow an attacking member to seize group control.  A member who attacks another in the group may unjustly hold another responsible for the reason he or she untimely chooses to terminate from the group.  When this occurs, it is helpful for the leader to practice reframing.  This means that the leader looks at negative actions by the attacker and responds in a less threatening and upbeat way.  Furthermore, the leader may block actions made by a member who attacks others.  A leader may also help this type of member by showing him or her how to initiate trust in a group.  This can be done by asking an attacking member to contribute, yet not demand taking part (Gladding, 2008).

The Member Who Stops Coming

In this situation, the group leader should contact the member and simply ask why he or she terminated prematurely from the group.  The member should then be asked to return and share with the group any opinions, reservations, or sentiments about the group.  The leader should also encourage this member to say good-bye to other members and reach a resolution and/or termination when needed.  Furthermore, the member should not be forced into continuing to attend the group.  The group leader should make this member aware of the advantages and obligations of maintaining membership in the group (Gladding, 2008).

References

Binford, R., Mussell, M., Crosby, R., Peterson, C., Crow, S., Mitchell, J. (2005). Coping strategies in bulimia nervosa treatment: impact on outcome in group cognitive-behavioral therapy. Journal of Consulting and Clinical Psychology, 73, 6, 1089-1096.  Retrieved from http://psycnet.apa.org.ezproxy.edu

Blechert, J., Ansorge, U., Beckmann, S., Tuschen-Caffier, B. (2011). The undue influence of shape and weight on self-evaluation in anorexia nervosa, bulimia nervosa and restrained eaters: a combined ERP and behavioral study. Psychological Medicine, 41, 1, 185-195. Retrieved from http://proquest.umi.com.ezproxy.liberty.edu

Clinton, T., Ohlschlager, G. (2002). Competent Christian counseling, volume one foundations and practice of compassionate soul care. Colorado Springs, CO: Waterbrook Press

Corey, G., Corey, M., Callanan, P. (2011). Issues and ethics in the helping professions, eighth edition.  Belmont, CA: Brooks/Cole.

Gladding, S. (2008).  Fifth edition: Groups, a counseling specialty. Upper Saddle River, NJ: Pearson and Merrill Prentice Hall.

Guez, J., Lev-Wiesel, R., Valetsky, S., Sztul, D., Pener, B. (2010). Self-figure drawings in women with anorexia; bulimia; overweight; and normal weight: A possible tool for assessment.  The Arts in Psychotherapy, 37, 5, 400-406.  Retrieved from http://www.sciencedirect.com.ezproxy.liberty.edu

Jacobs, E., Masson, R., Harvill, R. (2009). Group counseling strategies and skills, sixth edition. Belmont, CA: Thomson Brooks/Cole.

Latzer, Y., Peretz, T., Kreutzer, S. (2008). Conflict-oriented cognitive behavioral therapy (CO-CBT): an integrative approach to the treatment of bulimia nervosa patients.  Clinical Social Work Journal, 36, 4, 373-383.  Retrieved from http://web.ebscohost.com.ezproxy.liberty.edu

Roberto, C., Grilo, C., Masheb, R., White, M. (2010). Binge eating, purging, or both: eating disorder psychopathology findings from an internet community survey. The International Journal of Eating Disorders, 43, 8, 724-731. Retrieved from http://onlinelibrary.wiley.com.ezproxy.liberty.edu

Schaffner, A., Buchanan, L. (2008). Integrating evidence-based treatments with individual needs in an outpatient facility for eating disorders.  Eating Disorders, 16, 5, 378-392.  Retrieved from http://web.ebscohost.com.ezproxy.liberty.edu

Shapiro, J., Berkman, N., Brownley, K., Sedway, J., Lohr, K., and Bulik, C. (2007). Bulimia nervosa treatment: a systematic review of randomized controlled trials. The International Journal of Eating Disorders, 40, 4, 321-336. Retrieved from http://web.ebscohost.com.ezproxy.liberty.edu

Striegel-Moore, R., Wilson, G., DeBar, L., Perrin, N., Lynch, F., Rosselli, F., and Kraemer, H. (2010). Cognitive behavioral guided self-help for the treatment of recurrent binge eating. Journal of Consulting and Clinical Psychology, 78, 3, 312-321. Retrieved from http://psycnet.apa.org.ezproxy.liberty.edu  

Tan, S. (2003). Empirically supported therapy relationships: psychotherapy relationships that work. Journal of Psychology and Christianity, 22, 1, 64-67. Retrieved from http://bb7.liberty.edu

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