Bulimics are generally better suited to the group approach than anorexics. They tend to be older, more socially involved, and thus less afraid of other people. But for many bulimics, dealing with others produces feelings of inadequacy, rejection, and worthlessness, feelings that drive them to seek solace in a heaping plate of food. Groups can provide a setting to improve social interactions. Groups work better if, as in anorexia, members are selected carefully. Some groups are comprised of members who have never been anorexic or who are all married, for example. Having patients of similar age reduces the risk that older patients will ignore younger patients who may have different concerns. However, groups are never “perfectly” compatible. It helps to have patients explore their differences in order to lower resistance and increase their willingness to engage in therapy. The goal should be to achieve a “good enough” fit among members.
One way of selecting a group is by severity of the illness. Patients who binge and purge frequently (at least once a day for several years) but who aren’t in immediate medical danger may need an intensive program with several sessions a week. Twice-a-week bingers might do better in a more relaxed program.
In any case, group therapy should focus on symptomatic eating behavior. When patients regain healthy control over their eating, they can work more productively on other issues.
One such issue is assertiveness. We spend a lot of time discussing ways of handling apologies, compliments, and criticism. One patient complained, “I always do exactly what my husband tells me to do. If I don’t he’ll sulk and pout and make me feel guilty. Maybe we bulimics need a ‘Just Say No’ campaign of our very own!”
Problems: As in anorexia, some common features of bulimia can interfere with group therapy. One writer, Janice M. Cauwels, put it this way: “Bulimics tend to distrust people, especially other women, and most of all bulimic women.”
Bulimics can be perfectionists. If other members of the group don’t quite live up to their expectations, they may feel frustrated or angry.
Some patients place too much emphasis on food. They may use a “verbal binge” as they would a food binge to escape from their feelings. Group should address this issue. For example, during one session a patient said, “Hilary talks so much about food that I feel like I’m stuck in quicksand. I think she’s just doing that so she won’t have to talk about her problems with her boyfriend.”
Some patients expect a “magic cure,” believing that if they just show up at group meetings their symptoms will disappear. The group can help them confront and deal with this misconception.
Gradually, members realize that getting better takes time and work.
As with any group, feelings of competition and rivalry may emerge among patients. In groups that have a more psychodynamic orientation, members – guided by the therapist – can explore such conflicts. Doing so usually results in a deeper understanding of how the patients’ feelings influence their past and present relationships.
Group therapy should offer patients positive role models. Sometimes, however, newer members may feel jealous or inadequate when they see how other people have succeeded at reducing their symptoms. Conversation should focus on such feelings, especially if the patient’s pattern is to binge immediately before or after the group session.
One final note: Eating-disordered patients with drug or alcohol problems need additional help, because such problems can both substitute for bulimic symptoms and trigger them. Abstinence from substance abuse is usually a prerequisite for successful eating disorder treatment.
*93/35/5*