Therapeutic Factors in Short-term Group Therapy for

Women with Bulimia

Michael Hobbs, M.R.C. Psych., M.Sc. Sandra Birtchnell, M.R.C.Psych., M.Sc.

Anne Harte, Dip. C.O.T. Hubert Lacey, M.D., F.R.C.Psych.

(Accepted 22 November 1988)

Several recent studies indicate that short-term group therapy, either alone or in conjunction with other therapeutic interventions, i s effective in the treatment of bu- limia. The nature of the therapeutic effect in group treatments of bulimia has yet to be elucidated. The study reported here represents a first step toward establishing what bulimic patients regard as important therapeutically in their experience of group therapy. The findings suggest that patients regard “nonspecific” factors such as realising shared experience, learning from the experience of others, and gaining hope from observing positive change in others as important as the more “specific“ factors such as gaining understanding into the nature of their difficufties. These findings have implications for the design and execution of treatment programs.

Over recent years, bulimia has been recognized as a source of considerable dis- tress and morbidity among young women. There now exist many reports of the treatment of bulimia with outpatient group therapy (critically reviewed by Oesterheld, McKenna, & Gould 1987), reflecting both the pressure to provide a cost-effective program that can cope with large numbers of patients and the clinical impression that meeting in homogenous groups may offer particular benefits to these patients. Three major types of group therapy with bulimics have been described; psychodynamic, cognitivehehavioral, and self-help groups (Brotman, Alonso, & Herzog 1985); but treatment packages reported describe many different combinations of intervention modalities.

Reports of psychodynamic group therapy emphasize common themes such

Michael Hobbs, M.R.C.Psych., MA., i s Consultant Psychotherapist at the Warneford Hospital, Oxford. Sandra Birtchnell, M.R.C.Psych., M.Sc., i s Senior Registrar, Anne Harte, Dip. C.O.T., i s a Therapist, and Hubert Lacey, M.D., F.R.C.Psych., is Reader & Honorary Consultant, Eating Disorders Clinic, Academic Department of Psychiatry, St George’s Hospital Medical School, Tooting, London SW17 ORE. Address all requests for reprints and other correspondence to Dr. Lacey.

International /ourna/ of Eating Disorders, Vol. 8, No. 6, 623-633 (1 989) 0 1989 by John Wiley & Sons, Inc. CCC 0276-34781891060623-1 1$04.00

624 Hobbs et al.

as the need for approval, perfectionism, and difficulties in relationships with men, and the special tasks of the recipients have been highlighted (Weinstein & Richman, 1984; Inbody & Jones-Ellis, 1985; Bauer 1984: Lenihan & Sanders 1984). The necessity for both insight-orientated and systematically structured prescriptive interventions has been stressed (Stuber & Strober, 1987). Boskind Lodahl and White (1978) are acknowledged as the first to report on the group therapy of bulimia, and they have achieved some success with an experiential/ behavioral group developed within a feminist perspective (White & Boskind- White, 1981). Although many authors recognize the improtance of the psychodynamic group experience, it is common for this to be combined with other therapeutic strategies in the treatment packages. Lacey (1983) reports an eclectic program, including an insight-oriented group together with the keep- ing of a food diary reviewed in individual sessions with a therapist who makes behavioral as well as psychodynamic interventions. Similarly, groups combin- ing psychodynamic and behavioral principles are described by Roy-Byrne, Lee- Benner, and Yager (1984) (techniques used included a food diary, insight, support, and educational/cognitive input), Dixon and Kielcot-Glaser (1984) (food diary, behavioral interruption, insight, assertiveness, and relaxation training), Stevens and Salisbury (1984) (food diary, psychodynamic, and cogni- tivehehavioral techniques), and Fernandez (1984) (food diary, psychodynamic and cognitive behavioral techniques, education). The outcomes reported gener- ally confirm the effectiveness of these packages.

Less emphasis is placed on the psychodynamic aspects of group therapy in the psychoeducational programs that have been reported. Johnson, Connors, and Stuckey (1983) have described a short-term group with a highly structured psychoeducational focus, which also included behavioral self-monitoring, as- sertiveness, and relationship training. Weiss and Katzman (1984) have re- ported a group where an initially didactic format was then followed by theme- centered exploration combined with a problem-solving approach to enhance adaptive coping. More recently, they have replicated this format, comparing outcome with a small no-treatment control group (Wolchick, Weiss, & Katz- man, 1986), suggesting that their strategy is effective. The group treatment re- ported by Huon and Brown (1985) combines psychoeducational input around structured topics, cognitivehehavioral interventions, relaxation, and assertive- ness training.

Several teams have now reported the successful adaptation for groups of the cognitiveibehavioral treatment approach, developed so effectively by Fairburn (1981) with individual patients. Schneider and Agras (1985) reported on two short-term groups employing a cognitiveibehavioral approach and have since compared this to nondirective exploratory group therapy (firkley, Schneider, Agras, & Bachman 1985). Dedman (1985) closely followed the cognitiveibehav- ioral method described by Fairburn and reports encouraging results on a single group of eight bulimic women. More recently, Lee and Rush (1986) compared cognitiveibehavioral group therapy with a waiting-list control group with a sig- nificant decrease in both binge and purge frequency in the treated group, actu- ally only four of the 15 subjects shared full remission. The University of Minnesota program (Mitchell, Hatsukami, Goff, Pyle, Eckert, & Davis, i984) team has reported on an intensive 2-month outpatient group treatment (Pyle, Mitchell, Eckert, Hatsukami, & Goff 1984). This is primarily behavioral in ori-

Therapeutic Factors 625

entation, with lesser emphasis on correcting cognitive and feminist issues. Ini- tial outcome reports are encouraging.

Some attempt has been made to compare the efficacy of different group treatment approaches. Yates and Sambrailo (1984) compared cognitivehehav- ioral group therapy and the same therapy with, in addition, specific behavioral instruction. The inclusion of specific behavioral instruction did not significantly affect the outcome, which was good for both groups. Comparing their cogni- tivehehavioral group therapy with nondirective exploratory group therapy, l rk ley et al. (1985) reported that, although a greater percentage of the patients in the cognitivebehavioral groups were not binging and vomiting at 3-month follow-up, and fewer dropped out of treatment, these results did not reach sta- tistical significance. Freeman, Sinclair, Turnbull, and Annandale (1985) carried out a random allocation control trial, comparing individual cognitive therapy, individual behavior therapy, and semistructured group therapy with a waiting- list control. In a preliminary communication, all three treatments are reported as dramatically effective in reducing the behavioral symptoms of bulimia in comparison with the control group.

Despite the large number of reports published in recent years indicating that bulimia can be effectively treated in groups of various orientation, it is less clear what contribution different elements may make to the efficacy of particu- lar treatment packages and whether a group format may have particular ad- vantages for this type of patient. Anecdotally, many authors have stressed the value of contact with other patients and the experience of sharing their fear, misery, and progress with others (Lenihan & Sanders, 1984). The homogeneity of the group facilitates self-disclosure, catharsis, and insight, and bulimic women express relief in meeting others with similar symptoms (Dixon & &el- cot-Glaser 1984). High levels of identification facilitate cohesiveness with a sense of mutual support and understanding (Loganbill & Koch 1983; Connors, Johnson, & Stuckey 1984). Groups may be particularly effective in encouraging participants to reveal the secret shame of their symptoms (Weinstein & Rich- man 1984; Bauer 1984). The group may be seen as a safe environment in which to explore conflicts, test unrealistic beliefs and expectations with peers, and de- crease the sense of isolation, alienation, and shame that accompanies bulimia. This present study was designed as a preliminary investigation of the thera- peutic factors in short-term group therapy for bulimia.

THE STUDY

The Treatment

This study investigates the experience of therapy of a cohort of five female patients receiving the eclectic outpatient treatment program for bulima devel- oped at St. George’s Hospital, London (Lacey, 1983). All the patients met the DSM-111 criteria for a diagnosis of bulimia (American Psychiatric Association, 1980), Russell’s Criteria for Bulimia Nervosa (Russell, 1979), and Lacey’s Crite- ria for a Diagnosis of Bulimia (Lacey, Harte, & BirtchneLl, 1986). None had a history suggestive of anorexia nervosa, and none abused drugs or alcohol.

The patients attended once weekly for 10 weeks. Each week, each patient

626 Hobbs et al.

first met for 30 minutes on an individual basis with one of the two female ther- apists (AH and SB), when they were weighed, the contents of their dietary di- ary examined, and both behavioral and psychodynamic interventions made. The five patients and two therapists then met together in a group for 90 min- utes. The group was conducted on conventional psychodynamic lines, facilitat- ing discussion of common and personal experience.

Method

The tool used to explore what the patients had found helpful in their experi- ence in the group was a derivative of the “most important event” questionnaire (Berzon, Pious, & Farson, 1963) described by Bloch, Reibstein, Crouch, Hol- royd, and Themen (1979). The questionnaire was worded as follows: ”Of the events which occurred in the last three meetings, which one do you feel was the most important for you personally? Describe the event, what actually took place, the group members involved, and your own reaction. Why was it so im- portant for you?”

Each patient was asked to complete this questionnaire at the end of sessions 3, 6, and 9 of the 10-week group. One patient did not complete the question- naire at session 6 because of absence. At the same points each of the two ther- apists recorded, independently of the patients and of her cotherapist, the event which she regarded as having been most important in the same three-session period for each of the patients.

Each recorded “most important event” was subsequently assigned to 1 of 10 therapeutic factors. Three judges (all qualified Group Analysts) used the man- ual devised by Bloch et al. (1979) to assign independently each of the patients’ (14) and the therapists’ (30) reported events, which had been randomly as- sorted. The manual gives a clear definition and operational criteria for each of the 10 factors. The judges were required to scrutinize the manual frequently while making the assignments and to select for each reported event the one factor which best represented its emphasis. Brief definitions of the 10 therapeu- tic factors are given in Table 1.

Results

The mean age of the patients was 24.4 years (range 21-30 years). Their mean weight was 65.5 kg (range 53.7-79.3 kg), with a mean percent mean-matched population weight of 107% (range 89-125%) calculated with reference to a standard table (Kemsley, 1953/1954).

The judges’ assignments of therapeutic factors to the events reported by each patient and both therapists for each patient during successive three-ses- sion periods are shown in Table 2. Patient A did not attend session 6 and did not, therefore, report on her most important event for sessions 4-6: the thera- pists did, however. There was full or partial agreement between the judges in assigning 41 of the 44 reported events, and a concensus decision was made subsequently about the assignment of those three reports about which there had been no agreement.

The judges’ assignments were scrutinized to establish the degree of agree-

Therapeutic Factors 627

Table 1. Brief definitions of the therapeutic factors.

Catharsis: emotional release leading to relief. Self-Disclosure: the act of revealing personal information to the group. Learning from Interpersonal Actions: the attempt to relate constructively and adaptively within

Universality: the patient perceives that other group members have similar problems and feelings

Acceptance: the patient’s sense of belonging, being supported, cared for, and valued by the

the group, either by initiating some behavior or responding to other group members.

and this reduces her sense of uniqueness.

group and her sense that she is unconditionally accepted even when she reveals something about herself which she has previously regarded as unacceptable.

Altruism: the patient feels better about herself andlor learns something positive about herself through helping other group members.

Guidance: the patient receives factual information, instruction, or explicit advice and suggestions about her problems from the therapist or other group members.

Self-Understanding: the patient learns something important about her behavior or assumptions or motivations or unconscious thoughts; this can come about through feedback, confrontation, or interpretation by the group (including the therapist).

observation of other group members (including the therapist).

progress, through group therapy.

Source: Bloch and Rubenstein (1980).

Vicarious Learning: the patient experiences something of value for herself through the

Instillation of Hope: the patient gains a sense of optimism about her progress, or potential for

ment between them in their assignment of each of the patients’ and therapists’ reports to 1 of the 10 possible therapeutic factors. The three judges agreed in the assignment of 37% of the therapists’, and 71% of the patients’, reports. There was partial agreement on 57% of the therapists’, and 21% of the pa- tients’, responses. Thus full agreement was reached on 48% of assignments and full or partial agreement on 93%. These figures compare favorably with those found by Bloch et al. (1979)-48% and 95%, respectively-in their study of long-term outpatient groups.

It is more difficult to assess adequately the validity of this research tool, but an analysis of concordance between the therapeutic factors perceived by each patient and the two therapists to be operating (according to the judges’ assign- ment of their reported events) in any three-session period are disappointing. Any degree of concordance was found in only 4 of the 14 (i.e., 29%) rated pe- riods and full concordance in only one (7%).

Table 3 summates and compares the factors identified by the patients and therapists as being important during the nine group sessions covered by the study. Patients and therapists concurred in ascribing value to self- understanding and, to a lesser extent, learning from interpersonal actions. Therapists also regarded the patients’ self-disclosure as important, in contrast to the patients’ own assignment of no value to this factor. Similarly the thera- pists regarded the patients’ experience of acceptance as far more important than did the patients themselves but underrated the value accorded by the pa- tients to factors reflecting other ”nonspecific” therapeutic opportunities of the group: universality, vicarious learning, and instillation of hope.

It would be valuable in examining these trends to differentiate “classes” of factors in order to elucidate further the therapists and patients’ different views of what was therapeutic in this group.

Berzon et al. (1963) differentiated affective (acceptance, catharsis, instillation

Tab

le 2

. du

ring

suc

cess

ive

thre

e se

ssio

n pe

riod

s.

Judg

es’ a

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nmen

t of

ther

apeu

tic f

acto

rs to

the

even

ts d

escr

ibed

by

the

patie

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them

selv

es a

nd th

e th

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ists

for

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tient

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ions

1-3

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ns 4

-6

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7-9

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Patie

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The

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st 1

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A

Uni

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ality

B In

terp

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nal

C

Vic

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us

D

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E U

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lear

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lear

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Self

-und

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Se

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Self-

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Se

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Self-

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Acc

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Therapeutic Factors 629

Table 3. patients and therapists.

Summary of therapeutic factors reported by

Factors Therapists Patients Totals

Self-unders tanding Self-disclosure Learning from interpersonal

actions Acceptance Instillation of hope Vicarious learning Universality Altruism Catharsis Guidance

7 (23%) 6 (20%) 3 (10%)

1(3%)

1(3%) 1(3%) 2 (6%) 1(3%)

7 (23%)

1 (3%)

3 (21%) 10 (23%) 0 6 (14%) 1(7%) 4 (9%)

1(7%) 8 (18%) 2 (14%) 3(7%) 3 (21%) 4 (9%) 3 (21%) 4 (9%) 0 1(2%) 1(7%) 3 (7%) 0 1(2%)

of hope), behavioral (self-disclosure, learning from interpersonal actions, altru- ism), and cognitive (self-understanding, vicarious learning, guidance, univer- sality) classes of factors. According to this classification, therapists in the present study regard affective, behavioral, and cognitive factors as equally im- portant (see Table 4). The patients attributed more importance to cognitive fac- tors and less to behavioral factors.

We regarded this classification as unilluminating and so attempted to divide the 10 factors into individual-centered and group-oriented items, the former re- flecting processes within or deriving from the individual patient (even if re- ceived by others) and the latter reflecting interpersonal processes which occur only or essentially in groups (see Table 5) . According to this classification, ther- apists seemed to accord equal importance to individual and group-oriented items, whereas the patients tended to favor the latter.

The shifts in importance attributed to different therapeutic factors by pa- tients and therapists as the group progressed from beginning to end are shown in Table 6. The findings suggested that self-disclosure and vicarious learning were more important in the early phase of the group, self-understanding in the middle phase, and instillation of hope in the final phase. Trends suggested that patients valued the experience of universality more in the early stages of the group.

No clear evidence emerged to confirm expected progressions of therapeutic experience in any one patient, although one or two trends could be shown. For example (Table 2) , patient C seemed to move from experiencing self-disclosure, vicarious learning, and self-understanding as important early in the group to, later, valuing acceptance and instillation of hope.

Table 4. therapists' perceptions i.n terms of "classes" of factors.

Comparison of patients' and

Classes Therapists Patients Totals

Cognitive 10 (33%) 9 (64%) 19 (43%) Behavioral 10 (33%) 1 (7%) 11 (25%) Affective 10 (33%) 4 (29%) 14 (32%)

630 Hobbs et al.

Table 5. Comparison of therapists’ and patients’ assignment, as therapeutically important, of factors which are “individual-centered” or ”interpersonal” in nature.

Therapists Patients Totals

Individual-centered items Self-understanding 7 (23%) 3 (21%) 10 (23%) Self-disclosure 6 (20%) 0 6 (14%)

Total 15 (50%) 4 (29%) 19 (43%) Interpersonal items

Catharsis 2 (7%) 1(7%) 3 (7%)

Interpersonal learning 3 (10%) 1(7%) 4 (9%)

Vicarious learning 1(3%) 3 (21%) 4 (9%) Universality 1(3%) 3 (21%) 4 (9%) Altruism 1 ( 3 % ) 0 1(2%) Guidance 1(3%) 0 1(2%)

Acceptance 7 (23%) 1(7%) 8 (18%) Instillation of hope (3%) 2 (14%) 3 (7%)

Total 15 (50%) 10 (71%) 25 (57%)

DISCUSSION

Methodological problems limit the conclusion to be drawn from this study. In part the limitation derives from the small size of the population studied, but the evidence available suggests that the validity of the research tool employed would not be improved by a larger study population, i.e., by more patients in more groups. Examination of the original reports suggested that discrepancies arose both from patients and therapists identifying different events as impor- tant and from the judges assigning even the same event to different therapeu- tic factors because of subtle differences in the patients’ and therapists’ reports. The term “event” seemed to create difficulty for whereas the patients tended to describe discrete events (as requested by the questionnaire), the therapists tended to describe less tangible “experiences” which were more difficult to as- sign to therapeutic factors.

The findings indicated that patients and therapists valued a combination of ”specific” (e.g., self-understanding, self-disclosure) and ”nonspecific” factors (e.g., acceptance, instillation of hope, vicarious learning, and universality) as therapeutic in this group experience. Trends showed the same bias toward ”specific” factors in therapists and toward “nonspecific” factors in patients as found in the study of long-term groups by Bloch and Reibstein (1980).

Of interest was the finding that the therapists rated self-disclosure and ac- ceptance more important and instillation of hope, vicarious learning, and uni- versality as less important than did the patients. Bulimia nervosa is experienced by its sufferers as a very private difficulty, and both clinical expe- rience and the therapists’ identification of therapeutic effects in this study sug- gest that ”public” disclosure of the disordered behavior can be an important step toward its resolution. As Fairburn (1981) wrote: ”Simply bringing the problem into the open seems helpful.” The fact is, however, that self-disclo- sure is a painful and distressing experience in itself which, according to these findings, is valued less by the patients than by their therapists. The patients’ lesser emphasis of acceptance may be a related finding, raising the possibilities

Tab

le 6

. Sh

ifts i

n im

port

ance

att

ribu

ted

to d

iffer

ent t

hera

peut

ic fa

ctor

s ov

er ti

me.

Wee

ks 1

-3

Wee

ks 4

-6

Wee

ks 7

-9

The

rapi

sts

Patie

nts

Tot

al

The

rapi

sts

Patie

nts

Tot

al

The

rapi

sts

Patie

nts

Tot

al

Self-

unde

rsta

ndin

g Se

lf-di

sclo

sure

L

earn

ing

from

inte

rper

sona

l ac

tions

A

ccep

tanc

e In

still

atio

n of

hope

V

icar

ious

lear

ning

U

nive

rsal

ity

Altr

uism

C

atha

rsis

Gui

danc

e

2 4 0

2 2 0 0 0

2 4 1

4 1

1

2 0 0 0 0 1 1

2 0 0 0 0 1 1

0 0 0

6 1

1

2 0 1 1 0 1 1

1 1

2 2 1

0 1 1 1 0

1 0 0 1 2 0 0 0 1 0

2 1 2 3 3 0 1 1

2 0

632 Hobbs et al.

either that they did not feel sufficiently accepted by each other to disclose pain- ful material or that (an explanation which fits better in view of the therapists’ reports) they did not experience their self-disclosures as accepted by each other.

Acceptance and universality may reflect different aspects of the same experi- ence. Participation in a homogenous group permits the bulimic patient to talk about her problem in the relative safety of a context in which all other patients share a similar experience. In such a group, as suggested by these findings, the realization of shared experience may enhance the sense of belonging and/or ac- ceptance in such a way that peer group pressure can be exercised maximally.

The patients’ attribution of importance to the related factors of vicarious learning (the patient sees how other group members improve) and instillation of hope (the patient sees that ofher group members improve) emphasized that they could benefit from the experience of others, and it could be that such po- tential was maximized in this homogenous group.

Group-analytic theory suggests that, collectively, a group represents a norm from which, individually, each of its members deviate. There is a danger that a homogenous group may emphasize a pathological norm, secretive binge-eating and vomiting in this case. However, the evidence from this study, in particular the patients’ regard for universality and learning from each other, indicates that therapeutic experience may even be predicated upon a degree of shared experience.

The work reported here represents a pilot study for further research into the nature of the therapeutic effect in the small group treatment of bulimia.

We are indebted to the “judges,” Janet Boakes, Tom Burns, and Pat Hughes, all Con- sultants at St George’s Hospital.

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