: Group Psychotherapy for Eating

Heather Harper-Giuffre and K Roy MacKenzie, Editors: 1992. American Psychiatric Press. ISBN 0 88048 419 5 (b’bk)

This book is based on the Toronto Hospital’s Eating Disorders Programme
 where a number of different types of therapy group are in progress, and 
contains extremely interesting reports from the various groups. There are 
chapters on Cognitive-Behavioural Group treatment for Bulimia Nervosa,
 Interpersonal Group Psychotherapy, Body Image Groups, Family Relations
 Groups, Sexual Abuse Groups, Adolescent Groups, Support and Self-help
 Groups and on Continuing Care Groups for Chronic Anorexia Nervosa.
 These groups all work within the medical context of the Hospital. I feel
 that the scope of the Toronto Programme and its project of combining 
many different approaches make this book vital reading tor any therapist
 involved in the field, and of great interest to a more general reader as well.

In their introduction, the editors say that they “see this book falling into
 the increasingly influential ‘integrated psychotherapy’ tradition that seeks 
to pull together concepts from various theoretical orientations.” When I 
read this, I wondered if what they were referring to as integrated
 psychotherapy’ would he recognizable in the humanistic sense, and I must
 make it clear that it is not. The Programme genuinely does “pull together”
 types of therapy whose theoretical bases are by no means easily made 
complementary to one another. The group processes involved are
 extremely different from each other; for example, the Cognitive-Behavioural Groups are ‘psychoeducational’ in contrast to the process-
orientated Interpersonal ones, and so on. Perhaps in an attempt to make 
this extraordinary variety into a coherent strategy, the editors have written 
an ‘Introduction to Group Concepts’ where they briefly explain a certain
 amount of group theory (including “Table 2:2 – Developmental stages in 
groups,” under the headings of Group Task, Individual Task and Therapist
 Task, a handy reference for group leaders, perhaps). This approach is 
extremely concise, and totally avoids any discussion of the philosophy on 
which the theory might he founded, presenting it almost as a factual entity.
 I must confess that I found this apparent certainty of approach was at odds 
with my own understanding of group and individual processes. I came to
 the conclusion that, within the medical framework of the research, issues
 about the person are simply subsumed once the diagnosis of an ‘eating
 disorder’ has been arrived at. I was quite torn, therefore, in reading the
 book, because it has such a wonderful breadth of psychotherapeutic
 material, contained within a paradigm which I felt to be basically out of sympathy with the philosophies of many of the group therapies which were included.

Having said that, I was surprised at the depth of insight achieved in some 
of the chapters on the particular groups, and I would most certainly 
recommend anyone who is interested in group therapies in general to have 
a look at these chapters. The different strategies emerge with startling 
clarity, perhaps because they are so starkly placed alongside each other in
 the context of the overall Hospital Programme. No attempt is made to
 mediate between them, or to resolve their inherent differences. Each
 chapter stands alone, looking neither to right nor left! Thus in the chapter 
on Day Hospital Group Treatment (as opposed to residential), the 
Description of the Programme gives one single paragraph in most cases to
 the “Menu Group” (‘primarily educational’), the “Nutrition Group” 
(‘didactic’), the “Eating Attitude Group” (also ‘didactic’), the “Assertion 
Group” (‘role-playing, behavioural’), the “Gym Group” (volleyball), the
 “Sexuality Group” (on sexual abuse), the “Family Relations Group” and the
 “Goodbye Group.” I am not sure whether all the people on the Programme
 attended all of this astonishing smorgasbord of groups, but two points
 emerged very clearly from this chapter: that groups are considerably more 
cost-effective to run than individual therapy programmes, and that they are
 probably also a great deal more effective therapeutically. The intensity of 
the Programme is striking, the high level of stimulation and the
 determination to attract the sufferer in one way if not in another. I 
wondered if the experience would be a bit like a Psychotherapeutic
 Fairground? And in a simple but fundamental sense, I feel that could be a
 good thing, in that it could genuinely facilitate the ‘patient’ to exercise 
choice. Underlying all the chapters, there seems to me to be a dark
 awareness of the serious and even potentially fatal consequences of the 
baffling ‘disorders’ they are attempting to alleviate.

Perhaps the most puzzling of all the approaches outlined for me was the 
”Interpersonal Group Psychotherapy” which claims to be ‘An Integrated 
Psychodynamic and Cognitive-Behavioural Framework.’ I found this 
chapter somewhat disturbing, in fact. The ‘psychoanalytic tradition’ seems 
to have been plundered for terms, but these are applied in the most
 diagnostic and inflexible fashion. “Personality disorders are commonly 
diagnosed in patients with eating disorders, most notably narcissistic and
 borderline features. These patients manifest problems in object constancy 
and integration. They demonstrate impulsivity and chronic feelings of 
emptiness…” This passage concludes that the ‘personality disorder’ may be
 so severe as to be a ‘counterindication’ to inclusion in the group. From a 
more humanistic standpoint, this labelling of and suspicion of a person’s
 actual feelings is most perturbing. It was at points like this that I felt most
 clearly the full force of the difficulty of ‘integrating’ therapy groups into
 medical settings. It was striking that it was only towards the end of the 
book, where there is a chapter on ‘Support and Self-Help Groups’ that I
 found the heading ‘Philosophy of Treatment.’ Indeed, in a quiet way, this chapter and the following one on ‘Continuing Care for Chronic Anorexia
 Nervosa’ did something to undermine the mind-set of most of the earlier
 chapters. For instance, I found here the positive assertion that “individual can fully resolve their food and weight issues and that an eating disorder is 
not an addiction.” (p251) The account of the processes of these two types
 of group were strikingly different from earlier chapters – a sense of the
 Rogerian ‘power of the group’ began to come through, in place of the
 standard of cost efficient treatment. And it was therefore most 
encouraging to find here, as in earlier chapters, tables of results which
 clarified and enhanced the written account of the groups. I felt that here was a rare example of the stringent statistical approach being well-
combincd with a thoroughly humane and even humanistic one.

I hope it is apparent that I hold this book in high regard as a major
 contribution to the subject, but even if this were not the case, I would have 
to recommend the book for its Appendix alone. This is an outstandingly useful document, called “The Road to Recovery”, which is a manual for 
participants in the Programme and which I feel should certainly be available to everyone who has an interest in eating disorders. It contains
 clear accounts of the physiological effects of starvation (including the ‘set 
point’ of one’s weight which is illuininatingly compared to the set point of
 one’s height), a brief but extremely helpful look at ‘the Multidetermined 
Nature of the Eating Disorders’ which is worth its weight in gold, and then of course some chapters on coping and recovery. This manual is available, I believe, from the Toronto Hospital, but I am not sure whether this offer 
applies outside Canada. In case it does, here is the address:

The Director, Eating Disorder Outpatient Clinic. The Toronto Hospital,
 College Wing, 1-328, 200 Elizabeth Street, Toronto, Ontario. M5G 2C4 

Mary Montaut