Group therapy is a challenge. Patients may feel bewildered at times. Change takes time-longer, perhaps, than they may think. They may feel discouraged. The rewards, though, can be great. They will enjoy a rare opportunity to have their thoughts and feelings recognized and accepted by others. This in turn will lead to new feelings: trust, closeness, and the sense of emotional support.

Early sessions: Patients introduce themselves and describe their experiences. Soon they find things in common-friends, feelings, even symptoms. I encourage these links between people, but at the same time work to draw in other members who may feel different or left out. All patients should have a chance to speak during the session, and there should be time at the end to discuss their reactions to the group experience.

Usually a patient is surprised to hear that other people share her thoughts or feelings. She may be surprised to hear girls (who even she can see are emaciated) stating that they feel fat.

Hearing someone express self-hatred or disappointment can stir up similar feelings in another patient, making her painfully aware of emotions she didn’t know she had. That’s the downside of “getting in touch with your feelings”-you may not like what you find. Patients may want to run away from this experience – and thus the group- to avoid dealing with it. But recognizing and talking about these feelings reduces their impact. I encourage patients to keep attending even if they are not yet able to express their feelings to the group.

A therapist in an eating disorder group, unlike the leaders of other types of groups, will usually encourage contact between members outside of the session. At the first meeting, patients exchange phone numbers; we encourage them to call each other as an alternative way of coping with their urge to binge or starve.

Later meetings: At first, patients may tend to direct their thoughts and feelings to the group leader. Eventually, though, patients speak more freely to each other. When that happens, the impact can be enormous. As one patient told me, “I couldn’t believe it-I gave someone in the group some advice and she actually took it! I really felt worthwhile for a change!” For many patients, such an experience may be the first time that something she says is listened to and treated as being of value.

Though each group is different, common themes emerge. At first, talk of eating behavior may dominate the scene: “I’ve forgotten how to eat,” “I don’t know what to eat or how much,” “I’m afraid that if I start to eat again I won’t know when to stop.” As time passes, other themes appear: assertiveness, the fear of displeasing others, anger, isolation, emptiness, and hopelessness.

Eventually patients explore broader issues, such as family relationships or the role of women in society. The issues vary depending on the age and background of the patients. While younger patients generally deal with problems of sexual maturity and the frightening path to adulthood, older patients may be wrestling with unstable marriages, child-rearing problems, or career choices.

As group therapy progresses, so do other forms of treatment. For example, patients often use their individual sessions to discuss feelings that emerge during group.

Progress in group therapy means symptoms grow less severe. Patients report that they have gained weight, their physical strength has increased, and they feel less bothered by cold. Success reinforces their commitment to therapy and gives others hope and encouragement.

Termination: Bringing group therapy to an end can be tricky. Groups stop meeting for many reasons: They reach the cutoff point agreed to earlier; the therapist leaves; members drop out. Leaving the group can be a sad and difficult time for some patients.

For each patient, leaving the group is a mixed blessing. On the positive side, it means stepping into the future armed with self-awareness. On the downside, some patients leave before they’re really ready, or they leave to avoid digging any deeper into their disorder.

Terminating therapy is easier if the group has been open-that is, without a fixed time frame or membership roster. In an open group, patients leave only when they feel ready. Leaving is a decision they make for themselves, a step toward autonomy. An open structure might mean a member can return to the group if she finds she needs further support.

Problems: The biggest problem with group therapy is the high dropout rate. The same factors that cause patients to drop out of any therapy group also affect eating disorder patients. These factors, as identified by Dr. Irving Yalom, include denial, low motivation, feelings of inadequacy, social insecurity, and fear of other people.

There may be external factors as well. The patient may be afraid to ask permission to leave work to attend a session, or her school activities may conflict. Sometimes her reluctance relates to difficulties with assertiveness or excessive rigidity.

Competition is often a problem: Patients may vie with one another to see who can be thinnest in the group. Members need to confront such rivalry directly and work through the problem during group discussions. Also, in individual therapy the patient has the therapist all to herself. Not so in a group. Sometimes patients feel they must compete for the therapist’s time and attention. If they fail, they feel inadequate or worthless.

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Soon, Kym was weighing herself three times a day: in the morning after she got out of the shower (to see if she had lost weight overnight), before dinner (to see if she had lost weight during the day), and before bed (to see if she had gained weight during dinner). Unfortunately, her scale seldom showed good news. By June 1997, she weighed 245 pounds.

Desperate to help Kym overcome her obsession with her weight, her husband smashed her scale. At first, she felt exasperated and frustrated. “It was sort of like having your addiction taken away from you,” she says. “I became very depressed about my weight.” But eventually, she was able to refocus her energy on a new interest: walking.

“My husband, who’s a runner, belongs to a group that includes runners and walkers. He kept asking me to join the walkers in the group,” she recalls. “I finally decided that I could sit either around and stay depressed or try something that might bring my husband and me closer together.”

On her first outing with the walkers, Kym trekked 1 miles. She hurt afterward, but she agreed to meet the group the following Saturday. Pretty soon, she was also walking 3 nights a week, either with her husband or a girlfriend.

By April 1998, Kym felt fit enough to add running to her fitness program. In October of that year, she joined a gym and weighed herself for the first time in months. She had lost 80 pounds, thanks largely to walking and running. And, as a bonus, she says, “My relationship with my husband has improved 1,000 percent. We’re spending more time together, and I’m not feeling depressed anymore.”

Today, at age 41, Kym is more concerned about how she looks and feels than how much she weighs. She’ll never again use a scale to measure her success.

WINNING ACTION

Stay off your scale. When you’re trying to slim down, don’t rely on your scale to measure your success. Because muscle is heavier than fat, your weight may not change much as you become more fit. Instead, some experts recommend using your clothes as a guide. Do your shirts and ST pants feel looser? Do you have more room in the waist? If so, celebrate. That’s the sign that you’re making progress.

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