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 Canada