GROUP THERAPY
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GROUP PROPOSAL: Component Elements- The presenting problem is Eating Disorders.
Feeding and Eating Disorders are defined by a continued perturbation of eating or eating-related behaviors that lead to changed consumption or absorption of food that considerably compromise physical health and psychosocial functioning. DSM V provides diagnostic criteria for Anorexia nervosa, Bulimia nervosa, Binge eating disorder, Pica, Rumination, Avoidant/Restrictive food intake disorder, Other specified feeding or eating disorders (Night Eating Syndrome, Purging disorder and subthreshold forms of Anorexia nervosa, Bulimia nervosa, and Binge eating disorder) and Unspecified Feeding or Eating Disorders. Eating disorder behaviors can contribute to obesity and vice versa. Binge eating disorders and Bulimia nervosa are the conditions most frequently studied in obese individuals due to their significant coexistence with high BMIs (Felipe Q. da Luz, 2018). Both obesity and eating disorders are affiliated with grim physical and mental health effects and severe psychosocial effects. A study in the United States showed that 42% of people had binge eating disorder at any stage of their life and had obesity at the time of the survey. Another study also found that 87% of people suffering from binge eating disorder and 33% of individuals suffering from bulimia nervosa suffered from obesity at a certain point in their lives (Felipe Q. da Luz, 2018). These studies were congruous with the fact that these two conditions can plausibly coexist, promote, or even aggravate each other (Felipe Q. da Luz, 2018). Eating disorders are relatively common in the United States, particularly amongst adolescents and young adults, with nearly 95% of all first-time cases occurring before twenty-five years of age. They are associated with lower overall quality of life and high mortality rates (Zachary J.Ward, 2019). Eating disorders have been estimated to have the highest mean annual prevalence at approximately twenty-one years of age for both male and female individuals (at 7.4% and 10.3%, respectively). Despite having lower estimated annual prevalence compared to other conditions, eating disorders have a high cumulative lifetime burden where the mean lifetime prevalence has been estimated to be at 14.3% for (roughly one in seven) for male individuals and 19.7% (approximately one in five) for female individuals by forty years of age (Zachary J.Ward, 2019).
The rationale for developing the group
A transdiagnostic cognitive-behavioral theory that extends the original theory of Bulimia nervosa to all eating disorders has been put forward. It states that eating conditions share some clinical features, most of which are attributed to their common core psychopathological feature; Overvaluation of body shape and weight. The patients judge their self-worth for the most part or even solely based on body shape, and weight and their control thereof and this may or may not coexist with the overvaluation of eating control where there is considerable worry about feeding control that causes the assumption of radical and extremist dietary restrictions and numerous and abnormal food checking (weighing and monitoring the exact caloric contents of the food they ingest). This overvaluation of eating control is driven by factors such as dyspeptic symptoms, asceticism for fear of being greedy, intolerance to post-prandial fullness rather than concern about body weight and shape. (Grave, 2013). Based on the Cognitive Behavior Theory, this core psychopathology feature forms the maintenance mechanism of eating disorder psychology. This is because the major clinical features of these conditions arise either as direct or indirect derivatives. This system of self-appraisal adopted by people with eating disorders is inherently flawed due to three main reasons; people who judge themselves principally based on a single set of physical features (the control of body shape and weight) compromise their entire self-appraisal program- risking the collapse of the whole system in the event of perceived failure, the fact that people suffering from eating disorders cannot achieve the ‘perfect figure’ makes it next to impossible to succeed in the control of body shape and weight, the overbearing dedication to controlling body shape and weight inescapably disparages the patient from other essential areas of life (school, relationships) that pitch in in the formulation of an effective, balanced self-appraisal system (Grave, 2013). The development of a preoccupation about shape is the inevitable outcome of people judging themselves based principally on a single domain. This locks the patients in a mindset where; their perception of internal and external stimuli is altered (for example to a point where they by preference only notice individuals with flat stomachs), they feel obligated to pursue unhealthy activities (self-induced vomiting, extreme dieting), they misbrand physical and emotional experiences to mirror their perceived body shape and weight (Grave, 2013). This mindset is linked to negative emotions; symptoms of depression and anxiety, self-harm and misuse of psychoactive substances, and personality traits like perfectionism, low self-esteem, and mood intolerance are often found to coexist with eating disorders (Grave, 2013). The group aims to help the affected individuals regenerate significant personality dimensions. This is done by facilitating interactions among group members, which creates an enabling, supportive environment that promotes an examination of the problem area- providing support, care, and constructive criticism (Marianne Schneider Corey, 2018).
Theoretical orientation to drive the development of the group
Cognitive Behavioral Therapy is one of the principles proven psychotherapeutic treatment approaches for eating disorders. Through it, affected individuals can appreciate the interplay between their thoughts, feelings, and behaviors and formulate plans to alter unhelpful thoughts and behaviors to better mood and functioning (Muhlheim, 2019). CBT is thought to be the most efficacious treatment approach for Bulimia nervosa. It has been advocated as the first-line of treatment for adults suffering from Bulimia nervosa, Binge Eating Disorder, and as one of the top three treatment options for the management of adults suffering from Anorexia nervosa by the UK’s National Institute for Care Excellence (NICE) (Muhlheim, 2019). A new ‘enhanced’ (CBT-E) variant that is more effective and applicable for all eating disorders has been put forward (JOANNA DUDEK, 2014). It is based on the transdiagnostic theory mentioned above and is meant to treat the eating disorder core psychopathology (Rebecca Murphy, 2010).
CBT-E is detailed in its structure with four defined stages (Carcel, 2016). There’s usually an initial assessment that evaluates the nature and extent of the patient’s condition before treatment can be initiated. This often happens over two or more sessions and is intended to put the patient at ease, to determine whether CBT-E is a suitable form of management, and to prepare them for treatment and change. Contraindications to the immediate commencement of CBT-E include; acute clinical depression, substance abuse, significant detracting life events, and contending obligations (Rebecca Murphy, 2010).
Stage one- starting well (first four weeks): This is a rigorous leadoff phase that is designed to create early therapeutic momentum. It aims to: immerse the patient in treatment and change, jointly make out an individualized formulation (case conceptualization) with the patient, educate the patient about the disorder and the treatment process, set up real-time self-monitoring, set up concerted regular weighing (weekly weighing is preferable), commence regular feeding (Rebecca Murphy, 2010)
Stage two- stock-taking (next two weeks): This is a concise, but crucial, adjustment and changeover step that’s usually handled in two weekly appointments where the activities in stage one are continued, and the therapist and patient take stock- analyzing progress, identifying obstacles that should be addressed, amending the formulation if necessary and formulating strategies for stage three (Rebecca Murphy, 2010).
Stage three- the main body of treatment (8 weeks): It aims to address the core psychopathology and other related and crucial processes perpetuating the patient’s eating disorder. The overvaluation of body shape and weight, dietary rules, event-related alterations in feeding, clinical perfectionism, low self-esteem, and interpersonal problems are addressed in order of their relative importance in perpetuating the eating disorder (Rebecca Murphy, 2010).
Stage four- Ending well (lasts two weeks): Emphasis shift to the future. The primary objectives are the maintenance of already made progress and formulation of relapse prevention strategies. This is usually done on an average of three appointments about two weeks apart (Rebecca Murphy, 2010).
Best forms of intervention
Group members may express apprehensions about being judged, which might hinder their participation in the group. These fears can be alleviated by putting interventions in place to provide encouragement, group cohesion, and build trust among the members. This can be done by Encouraging member-member interaction which is facilitated by encouraging members to open up about fears, and concerns about body shape and weight (members can also be encouraged to share their concerns with other group members that they feel connected to), exploring member fears where members’ fears are explored in a healthy non-threatening manner which forms the basis for building trust and cohesion in the group.
Objectives and Goals of the group
The group’s short term objectives are the articulation of a precise comprehension of how eating disorders develop, articulation of an accurate awareness of the logic behind and the goals of treatment, identification of trigger for unhealthy eating or maladaptive weight loss practices, expression of a basis for positive identity based on character traits, and relationships but not on weight and appearance, building skills to manage urges to engage in unhealthy eating practices or weight loss activities
The group’s long-term objectives are Successful discontinuation of the eating disorder with a resumption of regular feeding habits, and maintenance of healthy weight, elaboration of healthy cognitive credence about self, directing the development of a positive identity and a pragmatic appraisal of body size, illustration of healthy interpersonal relationships and formulation of relapse prevention strategies.
Type of group being proposed
Psychotherapy group. These groups help members ameliorate psychological troubles and interpersonal challenges of living. Group members usually suffer from acute/chronic mental/emotional conditions that manifest as difficulties in functioning at school or the workplace, causing significant distress. The group aims to help the affected individuals regenerate significant personality dimensions. This is done by facilitating interactions among group members, which creates an enabling, supportive environment that promotes the examination of the problem area- providing support, care, and constructive criticism (Marianne Schneider Corey, 2018).
The overall goal of the group
The purpose of the group is to increase self-esteem by exploring identity, based around the five factors in the Indivisible Self-model of wellness, with an emphasis on the coping of self
Where group members will come from
Referrals from the Department of Behavioral Health (Andrea Auxier, 2012). Dynamic linkages and agreements with behavioral health providers will need to be set up to enhance access, communication, and coordination between disciplines (Laura Galbreath, 2015).
Open or Closed group
This will be an open group that admits new members when other members leave- changing membership. This increases the chance of members interacting with a variety of people, which is a more accurate representation of everyday life. A high client turnover can however, lead to lower cohesion (Marianne Schneider Corey, 2018).
Homogenous or Heterogenous
A homogenous group with a target population of female patients (18-40 years old). These groups experience a higher degree of cohesion due to their members’ similarity, which allows for a greater expression of feelings and a more intensive analysis of life experiences (Marianne Schneider Corey, 2018).
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Flyers around the clinic as well as word of mouth
Inclusion Criteria
Female patients aged 18-40 years old, a primary diagnosis of an eating disorder during initial contact with a licensed medical practitioner (clinical referrals for individuals meeting DSM V criteria for any of the eating disorders), patients with a high level of insight from the Schedule for the Assessment of Insight – modification for ED (SAI-ED), and medically stable patients.
Exclusion Criteria
People who refuse to participate, People who are unable to appreciate and respect group agreements, People suffering from acute clinical depression, People suffering from substance abuse, People with significant detracting life events, and People with contending obligations (Rebecca Murphy, 2010).
Screening process
The SCOFF questionnaire has proven to be very useful as a screening tool for eating disorders. It is especially helpful due to its high sensitivity, its simple nature, its memorability, and its relatively easy administration and scoring (John F Morgan, 2000).
The SCOFF questions:
Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost control over how much you eat?
Have you recently lost more than One stone in 3 months?
Do you believe yourself to be Fat when others say you are too thin?
Would you say that food dominates your life?
One point is awarded for every “yes” answer; a score of >2 indicates a likely case of anorexia nervosa or bulimia nervosa. (Sensitivity 100%; Specificity 87.5%) (SARAH D. PRITTS, 2003).
The Schedule for the Assessment of Insight-modification for ED (SAI-ED), will also be used to assess the patient’s level of insight before admission to the group (G. Konstantakopoulos, 2011). It is made up of seven items. The patient gives a positive, negative, or ‘unsure’ answer for each question.
Do you think you are experiencing any emotional or psychological changes or difficulties?
Yes/Unsure/No
Do you think your condition amounts to a psychological/nervous disorder?
Yes/Unsure/No
Has your nervous /psychological condition led to adverse consequences or problems in your life?
(For example, conflict with others, neglect, financial or accommodation difficulties, irrational, impulsive or dangerous behavior, physical deterioration, work difficulties)
Yes/Unsure/No
Do you think your current condition or the problems resulting from it warrant (need) physical treatment?
Yes/Unsure/No
Do you think your current condition or the problems resulting from it warrant (need) psychological treatment?
Yes/Unsure/No
Do you think that eating-related problems represent a part of your current nervous/psychological condition?
Yes/Unsure/No
How do you feel when people think you are overly preoccupied with your weight, shape, eating?
That’s when I know I’m sick/I’m confused, and I don’t know what to think/They’re wrong
A score of 1 is awarded for each positive answer (intact insight), and a 0 is awarded for both negative and unsure answers (impaired insight) (G. Konstantakopoulos, 2011)
Informing group members of their acceptance to the group
Patients coming in from clinician referrals will be assessed for suitability for the program. Their contact information will be collected and used to reach them if they are admitted to the group.
How will those not admitted into the group be served
Those not admitted to the group will be offered continued support at the clinic.
Informed consent
The informed consent will be discussed and signed on the first day of the group for the client. They will be presented with information in a simplified way that they can understand. The information discussed will include: their rights to and extent of confidentiality, policies about engagement dates and charges, psychotherapist credentials, approaches employed in the group, and merits and demerits of being part of the group (Marianne Schneider Corey, 2018).
Recording members’ progress
Members’ progress will be noted to a case by the group leader (therapist/counselor) through structured data gathering on individual member experiences. This will help the group leader make alterations to ameliorate the intervention process.
Group format, structure, and setting
Meeting format: Pre-meeting (give members a chance to familiarize with each other prepare for the start of the meeting), Meeting start-up, Participant check-in, Education segment and Sharing time, Meeting close. The meeting set will be the Mental Health Agency (DBH). This setting offers privacy and is large enough to accommodate all members seated in a circle, which allows for direct visualization of all members and smooth movement.
References
Andrea Auxier, C. R. (2012). Behavioral health referrals and treatment initiation rates in integrated primary care: a Collaborative Care Research Network study. Translational Behavioral Medicine, 337-344.
Carcel, M. (2016). Enhanced Cognitive Behavioral Therapy for Eating Disorders. Retrieved from Mirro Mirror Eating Disorder Help: https://mirror-mirror.org/getting-help/enhanced-cognitive-behavioral-therapy-for-eating-disorders
Felipe Q. da Luz, P. H. (2018). Obesity with Comorbid Eating Disorders: Associated Health Risks and Treatment Approaches. Nutrients.
- Konstantakopoulos, K. T. (2011). Insight in eating disorders: Clinical and cognitive correlates. Psychological medicine, 1-11.
Grave, R. D. (2013). Multistep Cognitive Behavioral Therapy for Eating Disorders. Lanham, Maryland: The Rowman and Littlefield Publishing Group, Inc.
JOANNA DUDEK, P. O. (2014). TRANSDIAGNOSTIC MODELS OF EATING DISORDERS AND THERAPEUTIC METHODS: THE EXAMPLE OF FAIRBURN’S COGNITIVE BEHAVIOR THERAPY AND ACCEPTANCE AND COMMITMENT THERAPY. ROCZNIKI PSYCHOLOGICZNE/ANNALS OF PSYCHOLOGY, 25-39.
John F Morgan, F. R. (2000). The SCOFF questionnaire, a new screening tool for eating disorders. The Western Journal Of Medicine, 164-165.
Laura Galbreath, A. W. (2015, August 19). SAMHSA-HRSA Center for Integrated Health Solutions. Three Strategies for Effective Referrals to Specialist Mental Health and Addiction Services.
Marianne Schneider Corey, G. C. (2018). Groups Process and Practice 10th Edition. Boston: Cengage Learning.
Muhlheim, L. (2019, October 2). Why CBT Is Usually Suggested for Eating Disorders. Retrieved from Very Well Mind: https://www.verywellmind.com/cognitive-behavioral-therapy-for-eating-disorders-4151114
Rebecca Murphy, S. S. (2010). Cognitive Behavioral Therapy for Eating Disorders. The Psychiatric Clinics of North America, 611-627.
SARAH D. PRITTS, M. a. (2003). Diagnosis of Eating Disorders in Primary Care. American Family Physician, 297-304.
Zachary J.Ward, P. R. (2019). Estimation of Eating Disorders Prevalence by Age and Associations With Mortality in a Simulated Nationally Representative US Cohort. JAMA Network Open.