Group Therapies for the Treatment of Bulimia Nervosa
Integrated or Sequenced
In one of the first documented integrated approach to group psychotherapy with Bulimia, Roy-Byrne, Lee-Benner, and Yager (1984) combined elements of CBT and psychodynamic therapies in a one-year therapy group. The researchers were unsuccessful in this attempt to integrate the two therapies, as group members began to dropout and treatment became threatened by the new and confusing uses of behavioral techniques. Although it was empirically unsuccessful, it provided a new pathway for integrated various effective treatment modalities. Based on the results of this study, Riess and Rutan (1992) proposed that a time-limited group may be an entrance into treatment for a new individual, an adjunct to another type of individual therapy, or a possible introduction to a more open-ended type of group therapy, such as psychodynamic group psychotherapy.
Integration of various theories and treatment models is different from a sequential approach. While integrated models attempt to intertwine important and effective aspects of established therapies throughout the course of the group, sequenced group therapy starts with one type of therapy, measures improvements, and moves on to another type of therapy within the same course of treatment (Nevonen et al., 1999). The purpose of a sequenced model is to use the most effective forms of treatment within one cycle of the group therapy process, and to determine its efficacy at various stages.
Riess (2002) proposed a sequenced, time-limited group therapy for Bulimia in an attempt to incorporate the various effective treatment therapies for this pervasive disorder. Studies have found that, despite empirical support for specific treatment modalities, they are underutilized by therapists (Riess, 2002). Therefore, the use of an effective, sequenced group treatment model that encompasses CBT, psychoeducation, interpersonal psychotherapy, and relational approaches may be the best avenue for therapists and individuals to pursue. Riess implemented a 12-session integrative group method on women suffering from Bulimia Nervosa. In the first three sessions, psychoeducation consistent with the didactic goals of CBT is utilized.
CBT techniques, such as self-monitoring of food intake or purging behaviors and cognitive restructuring, emerge more prominently in sessions four through seven. Moving into the interpersonal psychotherapy (IPT) session (eighth and final session), emphasis is placed on the meaning and structuring of relationships, interpersonal conflicts and difficulties, and role expectations are discussed. Conclusions from this pilot study demonstrated improvement in binge-purge behaviors at the one year follow-up, which, along with the ease of implementation of these approaches, Riess believed would help this type of treatment for Bulimia have wide applicability.
Sequenced group therapy models are a relatively novel approach for the treatment of Bulimia. Several researchers agree that a sequence of interpersonal psychotherapy (IPT) and CBT may be the most effective for reducing binge eating and helping members who are struggling with Bulimia (Nevonen et al., 1999). It has previously been established that individual CBT therapy is an effective treatment modality for Bulimia. IPT, a short-term, focused psychotherapy mentioned previously has also been shown to be effective for individuals with Bulimia (Nevonen & Broberg, 2006). Perhaps it is that both forms of treatment effectively address interpersonal problems in different ways, which seem to be a critical component to the maintenance of bulimic behaviors, such as binge eating. Nevonen and Broberg (2006) claim that CBT and IPT “work through different mechanisms but reach the same outcome” (p. 118).
In the study by Nevonen and colleagues (1999), the aim was to develop a sequenced treatment model that was effective in reducing bulimic symptoms as well as addressed interpersonal problems, and develop a group therapy manual. Additionally, Nevonen et al. aimed to evaluate the efficacy of the group therapy model in terms of eating behaviors, attitudes, and habits, interpersonal issues, psychopathology, depression, coping, and body mass index.
As a detailed example of how sequencing works, Nevonen and colleagues’ treatment model offers a detailed step-wise approach. Step 1 was the CBT portion of the treatment, and included seven group sessions over seven weeks. The first part combined educational materials with addressing ways in which to correct distorted cognitions, while establishing regular eating patterns to diminish bingeing and purging behaviors. After evaluation of the CBT section and preparation for the upcoming IPT portion of treatment, members attended 13 interpersonal therapy sessions over 13 weeks. The interpersonal section of the treatment model did not focus on Bulimia, but instead focused on interpersonal conflicts, grief, role transitions, and interpersonal deficits (Nevonen et al., 1999).
The entire treatment model encompassed 20 group sessions over 20 weeks in one semester. Results of this study indicated that the CBT-IPT group therapy model was effective in reducing bulimic symptoms, decreasing general psychopathology, reducing interpersonal difficulties, and developing coping strategies (Nevonen et al., 1999). At one-year follow-up, researchers found sustained improvement in the reduction of bulimic symptoms and interpersonal issues.
In 2006, Nevonen and Broberg expanded their study to determine whether individual sequenced therapy of CBT and IPT was as effective as sequenced group therapy in long-term (2.5 year) follow-up results. In terms of recovery and remission of Bulimia at post-treatment, both individual and group CBT-IPT sequenced therapies were effective (Nevonen & Broberg, 2006). Nevonen and Broberg argue that, because group therapy is more cost-effective, it should be the first step in a stepped care approach, specifically if there are more interpersonal problems than bulimic symptomology. Thus far, sequenced approaches for group therapy with Bulimia seem to be the most effective approach with potential for longstanding psychotherapeutic effects.
In a comparison of a guided self-help approach to a cognitive-behavioral (CBT) method, Bailer and colleagues (2003) found that both treatments had substantial impacts on binge eating and purging behaviors. Bailer and colleagues used a sequential approach, whereby the use of a self-care manual followed by eight sessions of CBT was just as effective as 16 full sessions of CBT. Their results suggest that less intensive treatments for Bulimia should also be explored more thoroughly.
Although the types of group therapies outlined above and many other group therapy approaches have been utilized with individuals struggling with eating disorders, only a few types of group therapies have been thoroughly researched, and even fewer received consistent empirical support. Cognitive-behavioral treatments for eating disorders have been the most commonly researched and empirically supported form of treatment. This may be due to the fact that CBT is a measurable form of treatment. As concluded previously, however, other forms of therapy may be incorporating several techniques from various psychological theories, which makes it more difficult to determine exactly which factors of the group therapy model are most effective in their own right.
Previous research has focused primarily on finding the single, most efficacious group therapy model, and therapists now have a better understanding of the different factors in group therapy that are most helpful for individuals with Bulimia. Unfortunately, as indicated previously by Riess (2002), empirically supported types of therapies are underutilized by psychotherapists. The next step would be to decrease the gap between treatment research and clinical practice (Nevonen et al., 1999) by finding more clinically significant group therapy models, rather than relying solely on statistically significant treatment. Perhaps identifying the unique and personal needs of the individual struggling with Bulimia may be a better way to uphold long-term gains made during group therapy.
Within the last few decades, Bulimia has emerged as a serious and pervasive eating disorder affecting a large number of males and females of all ages. We now know that more males are developing disordered eating and eating pathologies of various forms, but research has yet to thoroughly examine a group therapy model for the treatment of males struggling with these issues. Tantillo (1998) recognizes a scarcity of theory or research addressing eating disorders in males, and even fewer ideas of how to address these concerns within a group context. In fact, a 1993 article in the Wall Street Journal examines a few men’s struggle with attending group therapy for a predominantly female therapy group. Many of the women in the group felt as though men could not have eating disorders, and often felt apprehensive and defensive toward the male(s) in the group. It is more common to find male-only therapy groups for eating disorders now, over 15 years later; however, men are still struggling with opening up about their disordered eating, because they are still subject to neglect and bias when they seek help (Stern, 1993).
More controlled and uncontrolled research and investigation of potential effective treatments for eating disorders for both males and females need to be examined. Overall, as evidenced by the review of several treatment modalities for Bulimia, different therapeutic elements and components of group psychotherapy theories are effective in helping decrease bulimic symptomology, bingeing and purging behaviors, interpersonal conflicts, and secrecy and shame, among other symptoms in females. Now is a good time to put this information to good use and develop several group therapy approaches for males and females with Bulimia, so they can finally break free from this dangerous and destructive disorder.
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