Reworking the Myth of Personal Incompetence: Group Psychotherapy for Bulimia Nervosa

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.

Women such as Lauren enter treatment possessed by an ego-alien compulsion. Isolated by their symptoms, they join together in group therapy to share, support, and enrich each other in a way different from any other previous experience. This point was illustrated when one patient asked another to describe a binge episode. As the patient described her odyssey from one restaurant to the next, the first patient admitted, "I thought I was the only person in the world who did that." For the bulimic patient, this universality of experience may exist only in the group.

Instillation of hope, interpersonal learning, and identification are among the most important therapeutic factors operative in the change process.⁴ When an experienced patient states to the neophyte patient, "I was once where you are now," the experienced patient becomes, at once, guide, inspiration and teacher. The following case studies illustrate this.

Case 1

Melody, an aging debutante in her 50s, was married with one small daughter. She presented for treatment with the complaint that she 'eats for three." She spent the major portion of her life worrying about her body size and the appearances of her home and child. Her activities revolved around exercise, charitable functions, and teas. She complained of dysphoria and free-floating anxiety bordering on panic.

In the group, she painfully described how badly she felt inside. She believed her life would he perfect if only she could lose 20 pounds. She had great difficulty understanding that the next bite of food would not magically obliterate the bad feelings and that fixing the outside would not alter the inner emptiness. She continued to focus on externals until one member gently confronted her, "We've heard a lot about your body, but we've not heard anything about your mind." The group accurately identified that her hunger was for a feeling of value. She painfully confessed her belief in her personal incompetence that she couldn't be anything but slim and beautiful. Her self-doubts were expressed in the following poem:

I am no good
I have no brain
Anything J achieve is by mistake
Therefore secretly
I VOMIT my achievements
I live through my body
My body is my only worth
No wonder I have so many
problems.

The group challenged this myth based on her active and intelligent participation with them. Melody became an important and respected group member. As the feeling of incompetence gave way to a more solid sense of self, she was transformed into a person with talents and ideas She helped the neophyte members work through their own feelings of incompetence and became a role model with whom others identified. At the time she left the group, she planned to return to school to pursue a graduate degree in design a sublimation of her concern with externals.

According to Yalom,4 the group recapitulates the nuclear family in ways that could never be accomplished in individual treatment precisely because the group feels like a family. Unconsciously, members take on the same role in the group that they assumed in their family-of-origin. The pathologic behavior is reactivated and reworked when the therapist and the patients, who symbolically represent the parents and siblings, foster the resolution of unconscious conflicts. Dysfunctional communication and pathologic behaviors can be identified; new behaviors can be practiced, and change can occur as the patient undergoes a corrective emotional experience. The following case illustrates this point.

Case 2

Nancy was a 42-year-old white married female who sought treatment for bulimia. Her parents died in a car accident when she was 6. Nancy was reared somewhat resentfully by her oldest brother and his wife. Despite the fact that she was physically cared for, her presence was barely tolerated. Sensing this reaction, she tried to be the nicest little girl in the world although she never felt loved.

Instillation of hope, interpersonal learning, and identification are among the most important therapeutic factors operative in the change process.

Nancy entered a stable and cohesive group 6 months after its inception. Although the group was prepared for a new member, they were not prepared for Nancy. During her first session in the group, Nancy began talking in a singsong fashion about her eating, her early life experiences, and then, tangentially, her philosophies. During the second session she continued to drone on. The experienced members of the group shifted uncomfortably until the leader interrupted Nancy's monologue to comment on the discomfort in the room. Annie a warm and verbal schoolteacher turned to Nancy. You know, you're acting like a 10 year old kid who doesn't know what's going on and who's trying to get the attention of the adults in the family by making nice. Maybe this is how you've coped since your parents died, but you don't have to make nice to be accepted here. We accept you because you, like me, have an eating disorder and you, like me, are in pain. That's enough."

Nancy was shaken by the gentle but constructive confrontation and threatened never to return to the group. In the next meeting, the therapist and members were able to help her process this valuable information. She was able to understand that being the "youngest person in the "family-group" had triggered regression, reactivating feelings of the frightened, abandoned child As she worked through these feelings Nancy came to acknowledge that binging had warded off her sadness for many years.

Several weeks after this confrontation, Nancy began behaving in an appropriate adult manner. Her speech became direct and forceful. She reported a decrease in the desire to binge and purge. Clearly this dramatic encounter was enabled by the group's ability to symbolically reconstitute the family-of-origin and rework the original trauma.

It may take years for each person to learn to share her deepest feelings and years for the core personality to change. For the eating-disordered patient whose trust has been compromised, group psychotherapy provides many opportunities to renegotiate this basic issue. As a result of this ruptured trust, the patient's life stance is basically one of pessimism and impending doom. Among the beliefs that color her world view is the conviction that she is not allowed to feel good, that she does not deserve happiness, that she is intrinsically bad.

In being nurtured and reciprocally being able to nurture others, the patient becomes allied with her own sense of competence and the competence of others. The constant reassurance of personal acceptance at last allows her to begin to reach out authentically to others. The axiom that the best way to help oneself is to help another is lived in the group. The goal of treatment for bulimia is not that the patient never binge and purge again. The goal of treatment for bulimia is that the patient feel like a complete person, profoundly connected to other human beings.

REFERENCES

• White RW. The Abnormal Personality. 3rd Ed. New York, NY. Ronald Press Co; 1964.
• Johnson C, Conners ME. The Etiolo;gy and Treatment of Bulimia Nervosa. New York, NY: Basic Books Inc; 1987:29-30
• Hendren RL, Atkins DM, Sumner CR, Barber JK. Model for the group treatment of eating disorders. Int. J. Group Psychother. 1987; 37:589-601.
• Yalom ID. The Theory and Practice of Group Psychotherapy. 3rd ed. New York, NY: Basic Books Inc; 1985.
• Roth DM Ross DR long term cognitive interpersonal group therapy for eating disorders Int J Group Psychother. 1988; 38: 491-509

Ms. Asner is Director, The Eating Disorders Foundation, Chevy Chase, Maryland.

Address reprint requests to Judith Asner, MSW, BCD, The Eating Disorders Foundation, The Barlow Building Suite 1435, 5454 Wisconsin Avenue, Chevy Chase, MD 20815

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