ATHABASCA UNIVERSITY
RE (DISCOVERING) WHO YOU ARE: BEYOND THE EATING DISORDER IDENTITY
AN 8-WEEK GROUP PROGRAM FOR WOMEN WITH EATING PROBLEMS
BY
AMELIA PERRI
A Final Project submitted to the
Graduate Centre for Applied Psychology, Athabasca University
in partial fulfillment of the requirements for the degree of
MASTER OF COUNSELLING
ALBERTA
February 2011
COMMITTEE MEMBERS
The members of this final project committee are:
Name of Supervisor
Name of Second Reader
Dr. Gina Wong-Wylie
Dr. Shelly Russell-Mayhew
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ABSTRACT
Eating disorders are serious and complex with multiple contributing factors. One of many issues
related to eating disorders is identity impairment. Women with eating problems often seem
consumed by their illness and it can appear as if the eating disorder has taken over their identity,
leaving them with little awareness about who they are as separate from the problem. An 8-week
group psychoeducational program informed by an extensive literature review was developed to
help adult women separate from the eating problem and reconnect with their (non-problem
dominated) sense of self. The program was developed based on the integration of feminist,
narrative, and Adlerian theories. In particular the focus of the program is primarily on identity
factors as opposed to eating disorder symptoms and behaviours. This offers a different approach
to solely focusing on eating disorder symptoms and can be beneficial to those beginning to
consider change or as an adjunct for those already receiving treatment for their problem.
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TABLE OF CONTENTS
Committee Members
ii
Abstract
iii
Table of Contents
iv
Chapter 1: Introduction
1
Problem Statement and Rationale
1
Structural Overview
9
Chapter 2: Theoretical Foundations and Supporting Literature
11
Defining Eating Disorders
11
Eating Disorders and Identity
12
Eating Disorders and Identity from a Feminist Perspective
16
Potential Approaches from a Feminist Perspective
20
Eating Disorders and Identity from a Narrative Therapy Perspective
23
Potential Approaches from a Narrative Therapy Perspective
26
Eating Disorders and Identity from the Adlerian Therapy Perspective
29
Potential Approaches from an Adlerian Perspective
31
Summarizing the Similarities and Differences in Perspectives and Approaches
33
Making the Case for an Integrated Approach
40
The Use of a Scrapbook
44
Group Process and Suggested Structure of the Group
45
Chapter 3 Procedures
48
Steps involved in the Process of Program Development
48
Chapter 4 Specific Product
50
Recruitment
50
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Screening
51
(Re) Discovering who you are: Beyond the Eating Disorder Identity, Weekly Sessions
55
Chapter 5 Synthesis and Future Directions
70
Benefits and Limitations
70
Synthesis
71
Future Directions
73
References
75
Appendices
88
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CHAPTER 1
Introduction
Problem Statement and Rationale
Many women, both young (Machado, Machado, Goncalves, & Hoek, 2007) and middle
aged (Gauvin, Brodeur, & Steiger, 2009; Marcus, Bromberger, Hsiao-Lan, Brown, & Kravitz,
2007), suffer from disordered eating. Although males also suffer from eating disorders, the
prevalence in males is significantly less than in females (National Institute for Mental Health,
2009).
Without intent to negate the relevance of eating issues for men, I will focus this project
on women given the greater prevalence. In a recent 2009 Canadian study involving phone
interviews with 1,501 women (aged 20-40 years) from Montreal, Quebec, Gauvin and colleagues
found that the prevalence of eating problems was significant. Their results indicated that none of
the women met the specific Diagnostic and Statistical Manual for Mental Disorders (DSM-IVTR) criteria for anorexia, however 0.6% met the criteria for bulimia, 3.8% of the sample met the
criteria for binge eating disorder, and 14.9% of the women experienced an eating disorder not
otherwise specified (details related to the definitions of the various eating disorders as defined in
the DSM-IV-TR will be described in Chapter 2). These percentages represented 290 of the
1,501 women, which was 19% of the sample (Gauvin et al., 2009), demonstrating a significant
percentage of women with an eating disorder. In two other studies, one on a Finnish sample of
2,881 women (Keski-Rahkonen, et al., 2007) and one on a sample of 2,028 Portuguese women
(Machado et al., 2007), anorexia prevalence was found to be 2.2% and 0.4% respectively.
Eating disorders are not just significant in their prevalence, but they are also considered a
serious mental illness due to the associated physical and psychological complications including
the high mortality rate associated with anorexia nervosa. Anorexia nervosa has the highest
mortality rate of all mental health illnesses as more than 10% of those with anorexia will die
1
from its complications (Birmingham, Su, Hlynsky, Goldner, & Gao, 2005; Centre for Excellence
in Eating Disorders, 2009). Complications include physical health risks (e.g., from the effects of
low weight and purging) and psychological health risks (e.g., the potential for suicide and other
mental health issues). What adds to the significance of these physical and psychological
implications of eating disorders are the multiple contributing factors related to their development
and maintenance (Polivy & Herman, 2002). For example, problems with personal control, low
self-esteem, sociocultural issues, perfectionism, genetics, emotion regulation issues, and
difficulty coping have all been cited as potential contributors to the development and
maintenance of an eating disorder (Polivy & Herman, 2002). An additional factor that has been
identified as a concern in the eating disorder population is identity impairment (Giles, 2006;
Maisel, Epston, & Borden, 2004; Polivy & Herman, 2002; Stein & Corte, 2007), which will be
the focus in this project.
Although there are a variety of formal definitions for identity impairment found in the
literature, I am using the term identity impairment to refer broadly to not having a clear sense of
one’s identity (including strengths, values, hopes, and interests). This can be captured by the
questions, “Who am I?” and “What is important to me?” It is important to note that I am not
suggesting that everyone with identity impairment issues will experience eating related
problems; however, as I will demonstrate in the next chapter it is a relevant factor to consider in
relation to eating disorders (Giles, 2006; Polivy & Herman, 2002; Stein & Corte, 2007). As a
result of poor identity development, an eating disorder may consume a person’s sense of self,
creating an identity dominated by the problem. Alternatively, a person may have developed an
identity, but then the eating problem became more and more dominant in her life, eroding her
established sense of self. The person’s identity then is impaired because it is consumed by the
2
problem rather than one’s strengths, values, intentions, interests, and hopes. For example,
feeling a lack of control or having low self-esteem can contribute to the use of the eating disorder
as a way to feel worthy (Belangee, 2007; Burns, 2004; Maisel et al., 2004). The eating disorder
can provide this false sense of worthiness, for example, through compliments for weight loss and
for having self-discipline. This and other identity issues related to eating disorders will be
discussed further in this project. A vignette is provided to illustrate how eating disorders can
consume one’s identity.
As Lisa lays down to bed she begins to review in her mind her eating plan for the
following day. She thinks about exactly what she will eat at precise times, counts the calories,
fats, and carbohydrates per meal and repeats this several times. She also thinks about
everything she’d eaten that day, focusing on what she didn’t do well in regards to food and how
she planned to compensate. As her partner tries to have a conversation with her, she can barely
focus on his words due to her obsessive thoughts about eating. She has no idea what he just
said. When she does finally fall asleep, she finds herself dreaming of food and her body. She
sees herself eating foods she craves that she will not allow herself to eat in reality, and as she
does eat these foods in the dream she sees her body grow larger and larger. The following
morning when she wakes up she tries on several outfits and none are good enough.
She feels
that her body is gross and nowhere near meets the standard she or society has set for what her
body should look like. She vows to work harder and do this right. When she gets to work, she
gets a compliment about her body as her co-worker mentions how thin and beautiful she looks.
Although Lisa has trouble accepting the complement, she is thrilled and feels (temporarily)
confident, successful, and in control. Later that day at lunch, there is cake to celebrate a coworker’s birthday and Lisa had a piece despite her thoughts not to. She then feels like a failure
3
and is consumed with guilt. She obsesses about how many different ways she might burn off
these extra calories that afternoon.
Later that afternoon, Lisa is talking to her mother who insists she should attend a family
get together even though she doesn’t want to. Lisa has trouble letting her mom know that she
will not attend and when she hangs up the phone, she plans how she will restrict her meals for
the rest of the afternoon and she does—giving her a sense of control and empowerment. Lisa is
then able to push aside worry about the issue with her mother. The following day, Lisa’s friends
are going out to a movie and despite having other things she wanted to do, she does not want to
disappoint her friends, so she goes. Lisa’s friends ask her what movie she wants to see and Lisa
says she doesn’t know and doesn’t really care. Her friends start to talk about their varying
interests and Lisa feels like a fish out of water. She has no idea what her interests are, other
than trying to maintain her weight. At times, though not a conscious thought, she feels that the
eating disorder is her only true friend and can’t imagine life without it.
Although this vignette is fictitious, it nonetheless captures the reality of some of the
struggles that women with disordered eating face and the preoccupation with eating. In a
generalized sense, this vignette demonstrates how women with eating disorders can be consumed
by their illness (Bulik & Kendler, 2000; Koski, 2008). Koski noted that women experiencing an
eating disorder had difficulty seeing beyond it; for example, they saw all of their problems as an
extension of the food issues in their life and perceived most life experiences through the frame of
what they put into their body. In other words, the women had difficulty accessing other parts of
their identity beyond the eating disorder. White (2007), one of the founders of narrative therapy,
referred to this as totalizing; that is, the person becomes the pathology or illness. This identity
4
crisis may have women inadvertently or unwittingly fearing recovery because they do not know
who they are or who they would be if they did not have the eating disorder.
Alternatively, some women have expressed gratitude for those that could see beyond
their illness and for those individuals that could see that there was more to their identity than the
eating disorder (Bulik & Kendler, 2000; Maisel et al., 2004). Further, Koski (2008) also
described the importance of helping women experiencing an eating disorder to view their
experience from a different frame in order to reduce the hold of the eating disorder. White
(2007) also supported this view that it is important for people to have an alternate identity (other
than the problem identity) to be able to overcome a problem. Consequently, it is important that
those working in the field of eating disorders continue to consider ways to help clients reconnect
with or develop a sense of self that is separate from the problem. Helping individuals with eating
disorders to develop a renewed sense of identity, one that is not centered on disordered eating
thoughts and behaviours, but includes other personal qualities, skills, and hopes may support
women to have a sense of who they are beyond the eating disorder. This positive identity frame
can then provide the opportunity for the individual to challenge the eating disorder, given a
different view of self that is beyond the eating disorder identity.
I am not proposing that work on developing an identity separate from the problem is the
treatment in and of itself however, I am suggesting that it can be a necessary element. If a
person is consumed by the problem identity, with little knowledge of an alternate identity, it will
be difficult for them to make changes in relation to the problem (White, 2007). Consequently,
the focus of this project work is to encourage separation from the problem identity and to
encourage the development of a more positive identity, from which healthier decisions can be
made (White, 2007). Once the person is grounded in a preferred self-narrative, I believe that
5
other interventions can be more useful as the person will have a different reference point (one
that is not dominated by the problem) from which to address change. Alternatively, other
treatments can be offered and positive change may occur. However, I believe that in addition to
this, developing a positive sense of self can contribute to long lasting change and personal
growth and development.
Issues related to identity impairments in eating disorders have not been well studied
(Stein & Corte, 2007) and eating disorders have been known to be complex to treat (National
Institute of Mental Health, 2009). There is not one superior type of counselling or
psychotherapy treatment known to be effective in treating all eating disorders, nor have there
historically been extensive studies on treatment approaches (National Institute of Mental Health,
2009). Furthermore, some researchers have proposed that randomized controlled trials may not
provide the best evidence of treatment efficacy, particularly for persons with anorexia (Treasure
& Kordy, 1998). Treasure and Kordy noted problematic areas in relation to inclusion criteria
(e.g., trying to treat a variation of issues with a specific treatment plan) and participant difficulty
with adherence to the treatment and follow up throughout the study period. There is some
evidence however that cognitive behaviour therapy is effective in treating bulimia, although
within this research there are also some limitations (Mitchell, Hoberman, Peterson, Mussell, &
Pyle, 1996). Before addressing these limitations, it is important to acknowledge the research that
demonstrates empirical support for cognitive behaviour therapy as an effective treatment for
bulimia. For example, Argas, Walsh, Fairburn, Wilson, & Kraemer (2000) evaluated the effects
of 19 sessions of cognitive behaviour therapy on 110 adult women with bulimia. At the 1 year
follow up, 40% of those that completed the treatment had recovered from bulimia. In addition,
Openshaw, Waller, and Sperlinger (2004) evaluated group cognitive behaviour therapy with 29
6
adult women and they found that 45% of the women had improved bulimia symptoms at the 6
month follow up. Despite some noteworthy outcomes with the use of cognitive behaviour
therapy, Mitchell and colleagues suggested that further research questions remain with regard to
the details of what else may contribute to effectiveness in treating eating disorders. For example,
they noted that the DSM-IV diagnosis of bulimia includes some arbitrary elements, such as the
criteria related to the frequency and duration of bulimia symptoms. In addition, they commented
on issues with screening for inclusion and exclusion, difficulties with follow up, issues with the
definition of “effectiveness”, concern about limitations related to self-reporting as the primary
measure, and they questioned the influence of prior treatment and the duration of the bulimia.
Given that there is no definitive effective theoretical approach identified in the literature
for working with all eating disorders, in this project I aim to integrate three theoretical
perspectives; narrative therapy, Adlerian therapy, and feminist theories to address the issue of
identity impairment within the context of work with eating disorders. The use of integrated
counselling approaches has been supported in the literature for eating disorders (Brown, Weber,
& Ali, 2008; Gremillion, 2004; Heenan, 2005) and in general in the field of counselling (Gold &
Stricker, 2006; Lazarus, 2005). Also, literature exists describing the similarities and integration
of Adlerian and narrative therapy (Disque & Bitter, 1998; Hester, 2004) as well as narrative and
feminist therapy (Brown et al., 2008; Gremillion, 2004). In Chapter 2, I will present the related
literature in regard to these theories and theoretical integration and how they relate to working
with identity issues and eating disorders. It is also important to note that this program will be a
group program, and it is a common practice to utilize group programs in work with eating
disorders (Corey, Corey, & Corey, 2010). Group approaches have been shown to have relational
benefits, such as, reducing shame and feeling supported, improvement in eating disorder
7
symptoms, improved trust in one’s own experience, and encouraging hope for recovery (Koski,
2008; Weber, Davis, & McPhie, 2006).
In addition to reflecting on the literature, the impetus for this project also stems from my
own work in the field of eating disorders. I currently provide both individual counselling and
facilitate group programs for women struggling with eating disorders and have been involved
with this type of work for four years. In individual counselling it has become apparent to me that
clients can benefit from having other (non-problem) areas of their identity accentuated. In other
words, if there is continued focus on the problem alone, then I have noticed that some clients can
remain dominated by the eating issues. Alternatively, by working with some clients to view
alternate aspects of themselves (in addition to other work), I have seen progress and
improvement in recovering from the eating disorder. Consequently, I became interested in
reviewing the literature on eating disorders, with special attention to identity factors, in more
detail to learn more about applying (identity) related interventions to my work. I would like to
reiterate that this focus on identity is just one part of the work and not the only approach
involved in working with women to recover from eating problems. However, I am seeing more
and more in my counselling work that this is an essential component and as such is the focus of
this project.
Up until this point, my counselling approach has mainly consisted of addressing identity
issues from a narrative therapy stance; however, I wanted to learn more about other therapies and
how they relate to this approach. The reason for selecting feminist and Adlerian perspectives (in
addition to narrative therapy) is based on my current knowledge of these theories and their
similarities and differences. I believe that these theories can be reasonably integrated due to their
similarities and can also be used effectively to offset the limitations between them. As such, the
8
focus in this project is on the idea of developing or re-connecting with a preferred identity from
these three different (and similar) theoretical perspectives of narrative, feminist, and Adlerian
therapy.
Up until this point, unlike in individual counselling work, the groups I have facilitated
focused on eating disorder behaviours and strategies to minimize these; with little focus on
developing alternate or preferred identities. Consequently, this project will allow me to
introduce a new focus for potential group work, which can be an adjunct to therapy the group
participants may already be receiving. This group program is not meant to be a therapy group
that addresses each individual’s issues in totality, rather it is a psychoeducational program to
encourage positive identity development and the desire to change or continue to change in
relation to the eating problem. Furthermore, I have noted in my own experience that one
theoretical approach does not suit everyone. Subsequently, this has provided the impetus for an
integrated approach. In the remainder of this project paper, I will focus on the development of
an 8-week group psychoeducational program for women suffering with disordered eating. The
program will center on the theme of supporting the participants to explore their identities through
three theoretical approaches. In summary, the focus of this project is on helping women to
separate from the problem and begin to develop an alternate, non-problem dominated sense of
self. This is proposed as one part of intervening to support women with an eating problem,
rather than an all encompassing approach.
Structural Overview
In the remainder of this project I will begin by presenting the literature of the theories that
form the foundation for the development of the program. This will include literature related to
eating disorders and identity issues, and these concepts within the three theoretical frames of
narrative, feminist, and Adlerian theories of counselling. In addition, I will outline the
9
theoretical underpinnings related to group process, the steps involved in the development of this
program, and then share a description of the product, the program itself. In conclusion, I will
describe the benefits, limitations, and implications of this project work as well as future
directions.
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CHAPTER 2
Theoretical Foundations and Supporting Literature
Defining Eating Disorders
Although eating disorders are definitively described in the Diagnostic and Statistical
Manual for Mental Disorders (DSM-IV-TR, 2004), it is in line with my theoretical preference of
narrative therapy to define and understand problems as described by clients and the language that
they use. This allows for the postmodern perspective of multiple truths and a subjective reality,
as opposed to a fixed truth or single reality (Lee, 2004). In addition to my theoretical preference,
there are also other issues to consider with the DSM-IV-TR definitions, which I present further
in the screening section of Chapter 4. Since the DSM-IV-TR does provide a common language
for professionals to work with, I will describe the eating disorder descriptions found within the
manual. At the same time, I will be commenting throughout this paper on some of the
challenges and effects associated with the use of dominant common language.
In the DSM-IV-TR anorexia nervosa is characterized by a weight that is less than 85%
than that expected for the individual, as well as a fear of gaining weight, a problem with how one
experiences their weight and shape (for example, significantly evaluating oneself based on
weight), and the absence of three consecutive menstruation cycles in women (American
Psychiatric Association (APA), 2000). Anorexia is further categorized into two types; the
restricting type and binge-eating/purging type. The distinguishing factor between these two
types is the absence of binge eating and purging in the restricting type and the presence of these
symptoms in the other type. Bulimia nervosa is defined in the DSM-IV-TR as recurrent bingeing
episodes and compensatory mechanisms (at least twice per week for three months) in an attempt
to prevent weight gain, and self evaluation that is unduly influenced by weight and shape
concerns (APA, 2000). Compensatory mechanisms in bulimia can take many forms, for
11
example, vomiting (purging type), laxative use (purging type), fasting (non-purging type), or
excessive exercise (non-purging type) (APA, 2000). Eating disorders not otherwise specified
(EDNOS) is another group of eating disorders defined in the DSM-IV-TR and essentially
includes eating disorder issues that do not meet the specific criteria for anorexia or bulimia
nervosa (APA, 2000). Some examples of criteria that would fall under the EDNOS diagnosis
are: meeting all of the criteria for anorexia except the person has regular menses, repeatedly
chewing and spitting out food but not swallowing, or binge eating without compensatory
behaviours that are seen with bulimia (APA, 2000). These DSM-IV-TR terms anorexia, bulimia,
and EDNOS are often used in the literature related to eating disorders, and this will be evident in
the next few sections as I share related literature.
Eating Disorders and Identity
Issues related to identity development and impairment in the context of eating disorders
have been noted in the literature and supported by many authors for decades. However, specifics
related to understanding this phenomenon have not been well studied (Stein & Corte, 2007).
Such paucity suggests the opportunity to understand this relationship better in order to help those
with eating disorders. The following is a description and summary of the literature from the
1980s and more recently to advance the connection between eating disorders and identity.
Bruch (1982) first described the possibility of identity development issues in adolescent
clients with anorexia. Particularly, she noted that a lack of a sense of self and lack of autonomy,
potentially contributed to by highly controlling parents, was apparent in the clients she worked
with. Furthermore, Bruch (1981, as cited by Stein & Corte, 2007) and Malson (1999) indicated
that the eating disorder was used as a way to define oneself, which has also been supported in
more current literature (Koski, 2008; Maisel et al., 2004). In a similar vein, other authors (e.g.,
12
Malson, 1999; Piran, 2001) noted how one’s body can be used to support a particular identity,
for example, self-discipline, as demonstrated by a thin body. Malson shared related thoughts of
people with anorexia in which she noted that due to a fear of being themselves the anorexia body
was a way to hide and fade away. Alternatively, one’s body could be unwittingly used in a
social sense to mean that a thin body represents success or self-discipline. All of these examples
demonstrate how eating disorders are linked to identity and furthermore how women may use
their bodies as symbols to communicate about culture, norms, and their experiences (Nasser,
Baistow, & Treasure, 2007).
In a more recent article related to identity and eating disorders, Giles (2006)
conducted a study of online conversations between people experiencing various types of
eating disorders. Data was downloaded from 20 different pro-ana websites (websites where
individuals with eating disorders can speak with one another) via messages that had been
archived for several months. Discourse was analyzed and information about what it means
to be “anorexic” and “bulimic” were noted. Amongst other themes, Giles recognized how
language can contribute to identity development. In other words, the language used in the
on-line discussions seemed to impact the identities that individuals would personify. For
example, anorexia was regarded as the “more superior” eating disorder in that those that had
anorexia had more self-discipline and self-control than those with bulimia.
To clarify, identity themes that emerged from Giles’ (2006) study included that
people with anorexia were regarded by themselves and others as having a high level of selfdiscipline and control (partly related to their ability to not eat). This was contrasted with
the identity of those with bulimia, who identified themselves and were identified by others,
as sick and as having an illness more so than those with anorexia. The female participants
13
within these dialogues had taken on the various diagnoses and labels attributed to them and
attached significant meaning to them. For example, some women viewed themselves as
failures for not being categorized as having anorexia or for having an eating disorder that
does not fit into a formal category of bulimia or anorexia. Other authors have also
supported this theme of failure in relation to eating disorders (Bulik & Kendler, 2000;
Maisel, et al., 2004). In these situations, the eating disorder appears to be taking over to
support negative ideas of self, for example, I am a failure. At other times, anorexia can be
seen as the only thing the person can be good at (Maisel et al., 2004), and so the eating
disorder dictates one’s identity as successful or failure. Further, if individuals living with
anorexia are seen as having control or success, this may make it more difficult for them to
consider giving up the disorder because it can feel like giving up an identity of being
successful or special.
In addition to these feelings of success and failure, some women with eating
disorders have tried to distinguish themselves from those without eating disorders and from
others within eating disorder groups in order to identify themselves as “special” or to have
an identity at all (Bulik & Kendler, 2000; Giles, 2006). This idea of specialness relates to
identity in the sense of being better than average. In other words, the eating disorder
becomes a symbolic (rather than actual) way to help one feel superior in relation to
dominant values such as, self-discipline or thinness. These women may in fact feel ashamed
of their problem as well. However, at one time the problem may have offered them an
opportunity for distinction (and praise), for example, “being the skinny one”, or “having
good self-control”. As Heenan (2005) described it, dieting or thinness can seemingly offer
“symbolic happiness” (p. 241). This can also represent conflict for women with eating
14
disorders in that on the one hand they are ashamed of the eating disorder problem, while on
the other hand there are some seemingly positive aspects that make it difficult to give it up
(e.g., recognition from others). Finding other ways for women to view themselves as unique
and worthy may be helpful in assisting them to feel this sense of “specialness” and to gain a
healthier sense of self. In summary, identity variables of success, failure, self-discipline,
self-control, specialness, and uniqueness are apparent in the literature reviewed thus far on
eating disorders and identity.
As an example of focusing on identity aspects, Bulik and Kendler (2000) described the
importance of helping a client with a 20 year history of struggling with an eating disorder to
establish an identity separate from the eating disorder. In this particular case, the client
described that she would have no identity if she gave up the eating disorder. This alludes to the
significance of identity issues in relation to eating disorders, for example, in this case, the eating
disorder was the client’s identity from her point of view. In this situation the client was looking
for others to acknowledge that there was more to her identity than the problem. The last phase of
work with this client focused on elaborating on parts of her identity that were not related to the
eating disorder. This helped her to continue to move further away from engaging with eating
disorder behaviours and symptoms, and created the opportunity for an identity not entirely
consumed by the eating problem. Although this study represented only one client’s perspective
(case study), it offers similar themes and findings to those in the other studies described
previously and in the remainder of this section.
Consistent with this perspective, Stein and Corte (2007) tested the idea that issues of
identity were related to the development of disordered eating symptoms. These researchers
measured self-concept in adult women with anorexia and bulimia as well as in a control
15
group. Women were given a questionnaire about self-schema which included a question
that asked them to list attributes that are important to who they are. They were asked to rate
the importance of these attributes in how they identified themselves and whether the
attribute was a positive, negative, or neutral one. Although the women with anorexia and
bulimia had more positive self schemas than negative, they also had less positive self schemas
and more negative ones than the control group, approximately 50% less positive self schemas
and 75% more negative self schemas than the control group. Although a causal relationship
between identity issues and eating disorders could not be claimed (i.e., the participants already
had eating disorders, therefore the identity issues may or may not have preceded the eating
disorder), these results indicate that those with eating disorders suffer from identity issues;
specifically a more negative self-concept compared to a control group. This further substantiates
the idea that addressing identity issues could be helpful for this population.
In addition to the identity issues described above, it is also noted in the literature that
there exists identity conflict issues in marginalized eating disorder groups, for example, with
women of colour (Harris & Kuba, 1997), in Asian women (Yokoyama, 2007), and with deaf
people (Moradi & Rottenstein, 2007). In considering the impact of cultural identity in
relation to the focus of this project, the issue becomes more complex and requires further
research beyond the scope of this project. However, it is noteworthy and important to
consider these cultural issues for future directions and implications. In the remainder of the
literature review I will move from these general themes about identity and eating disorders
to understanding the relationship of eating disorders and identity from three different
theoretical perspectives: feminist, narrative, and Adlerian.
Eating Disorders and Identity from a Feminist Perspective
16
Eating disorders are generally regarded as a woman’s issue (Lalande & Laverty, 2010;
Nasser et al., 2007), with approximately 90% of individuals reporting an eating disorder being
women (National Institute of Mental Health, 2009). As such, the issue of gender in relation to
eating disorders cannot be denied. Feminist perspectives on eating disorders include the idea
that they are developed within a sociocultural context that overemphasizes thinness as beauty
(Nasser et al., 2007), in which women experience oppression and may gain a sense of power and
control from the eating disorder (Black, 2003; Burns, 2004; Malson & Burns, 2009; Scott, 2008).
The power and control can be obtained from focusing on being rigid and controlling what one
eats, as well as attempting to control one’s appearance. In such instances women can be using
their bodies or the eating behaviours to experience identity elements such as being successful,
feeling worthy, or having control. The oppression women experience may stem from the
sociocultural pressures to be thin (Wong-Wylie & Russell-Mayhew, 2010). Women may then
not have the opportunity to develop other identity aspects as they are focused on fitting in with
this dominant beauty ideal.
Furthermore, feminist theorists believe that people are affected by the institutions of
society (e.g., the dominant culture, medical institutions, gender inequalities), and as such, these
theorists are interested in minimizing power differentials among people (Feminist Therapy
Institute, 2008). Furthermore, feminists believe that eating disorders are not an individual
internal problem, but rather a problem that is situated within a cultural context of gendered
power imbalances (Malson & Burns, 2009). Consequently, in considering such institutions of
society and contextual factors from a feminist perspective, one must consider the dominant
White male perspective of the Western world, beyond thinness and beauty ideals. The dominant
culture can represent several identity clashes for women. For example, the
17
dominant culture values individualism, which may present a conflict for women who may value
relationships and family. This can present an identity conflict about how a woman “should be”,
for example, should she go against her authentic values to meet societal expectations? When this
type of conflict occurs, a woman can experience identity issues. Alternatively, in some cultures
there may be an expectation that women value relationships and family over individualism, and
for women that feel they do not fit into this expectation; this can also present identity conflict
issues.
Cummins and Lehman (2007) also supported the notion that eating disorders have
societal and cultural roots related to the oppression of women. These authors specifically
presented identity concerns for the Asian female population, however many of the issues
presented could also apply to women of other cultures. For example, the authors noted that some
Asian women may struggle with their identity as family oriented and collectivist in a dominant
western culture where individualist ideals are upheld. This collectivist view can be considered
relevant in other cultures as well, such as in First Nations and Italian cultures. Many women
have family oriented ideals regardless of ethnicity and this can present an identity conflict in a
male dominated society that values individualism. These conflicts can then influence women in
such a way that they feel inferior and perhaps questioning of their identities, leading to the eating
disorder as a way to correct or cope with these issues. For example, they may use the eating
disorder to feel a sense of control or self-discipline, which can be experienced as a step towards
individualism. This may contribute to anorexia being valued by some women, because it allows
them to identify with these characteristics (Burns, 2004), for example, through restricting their
eating. In summary, the examples and issues presented above demonstrate how the dominant
culture may encourage oppression and identity issues in women with eating disorders, that is;
18
they may identify themselves as not fitting in, or a failure, and then potentially use the eating
disorder to fit an ideal (such as thinness, individualism, having control, or having self discipline)
which is often unattainable.
In addition to emphasis on certain values and ideals (Nasser et al., 2007), the institutions
of society also place emphasis, value, and therefore power on categorizing, labelling, and
diagnosing, which can negatively impact a woman’s identity in dealing with an eating disorder
(Burns, 2004; Malson & Burns, 2009; Scott, 2008; White, 2007). For example, diagnoses and
labels can lead to stigma and contribute to a sense that the person is just an illness or has
something “wrong” with them, with little else as part of their identity. For this reason, and the
significance placed on diagnoses and labels, discourse about mental illness and eating disorders
can negatively impact a woman’s identity by leaving little room for positive aspects of self to
emerge.
An effect that may stem from such pathologizing discourse is that focusing solely on
eating disorder symptoms and behaviours rather than including contextual factors can further
contribute to identity concerns (Koski, 2008). If during the process of recovery women are
treated for their behaviours alone, they may come to understand the eating disorder as an
individual illness and solely a problem from within themselves, potentially leading to an identity
encompassed by the eating disorder. Conversely, considering feminist perspectives, such as the
impact of gender role expectations and societal ideals could allow for the opportunity to consider
other influences on the problem and subsequently a less internalized and individualistic view of
the problem. This then can lend to the opportunity for positive identity development or
awareness, by recognizing problems beyond an individual.
19
Similar to considering diagnoses and labels as contributing to issues of identity in eating
disorders, the consideration of language and its effects on these issues also becomes apparent.
The feminist poststructuralist principle supported in Burns’ (2004) study was that language
affects the way people make meaning of their experiences. In this study, 15 women with
anorexia and bulimia and those working in the field of eating disorders were interviewed. The
researcher found that those working in the field assigned different identities (supported through
their use of language) to anorexia and bulimia. For example, anorexia was known to be
associated with ideas of perfectionism and a sense of control, whereas bulimia was identified as
having little control and more in line with a sense of failure rather than success. These results
were similar to those found in Giles’ (2006) study noted above. These labels can further
contribute to identity issues for people with eating problems in that they can become all
encompassing. For example, if anorexia is on some level seen as having control or equalling
success, this might make it more difficult to consider letting go of the disorder because this
might include shedding this identity and leaving what might seem to be little behind in terms of
the person’s identity. In consideration of these feminist perspectives on identity and eating
disorders, I will now present potential approaches in addressing the issue of identity from a
feminist perspective.
Potential Approaches from a Feminist perspective
From the literature presented above, I have surmised that from a feminist perspective
several factors can affect one’s identity when dealing with an eating disorder. For example,
Western (or other) cultural factors about whom and what a woman should be on the inside and
out can conflict with how a woman wants to be, which can then create identity struggles. In
addition, the eating disorder can take over in terms of how the person identifies themselves; this
20
is impacted by those that work in the field, other people, through diagnoses, labels, media
messages, and dominant discourse. This can lead to the identity issue of lacking an authentic
sense of oneself. Furthermore, the eating disorder can provide an identity the person may be
longing for such as a feeling of being special, in control, self disciplined, or successful.
Many authors have proposed feminist approaches to working with these issues. Some of
these authors have demonstrated that having a feminist identity contributes to protection from
eating related issues, protection from body image disturbances, and supports a sense of overall
well-being (Sabik & Tylka, 2006; Yakushko, 2007). Conversely, others have shown that there is
no correlation between a feminist identity and eating disorders (Green, Scott, Riopel & Skaggs,
2008). Sabik and Tylka demonstrated that women who had a more developed feminist identity,
for example, those that were committed to social change and believed that men and women could
be equal, were less impacted by sexist events contributing to eating disorder development.
Consequently, women with a feminist identity may be less inclined to accept traditional gender
roles and expectations, thereby reducing the likelihood of internalizing dominant societal views
such as the thinness ideal. As an example supporting this view, Yakushko conducted a study
involving 691 participants from the general public. Yakushko found that a feminist identity and
feminist values were correlated with a subjective sense of well-being. She also found that those
with more traditional values did not have this same sense of well-being. Further, Yakushko
suggested that women with non-feminist identities may feel they have less autonomy, growth in
life, and purpose in life. She noted that this information can be shared with women to help them
learn of the potential drawbacks of a non-feminist attitude. Consequently, addressing the issues
of empowerment, autonomy, and purpose in life may be helpful in working with women and
identity issues.
21
These factors are similar to the ideas within narrative therapy of personal agency and
one’s identity being linked to values, purposes, intentions, and hopes (White, 2007), which will
be discussed in the next section. Encouraging a sense of empowerment and autonomy may also
help reduce the need for the eating disorder to provide a sense of control, success, or selfdiscipline, as the person can experience these factors in other ways. Lastly, addressing
empowerment can also support healthy identities in women that are using their bodies and eating
behaviours to express their feelings, in that they can learn to develop their voice in order to speak
about and process their feelings (Heenan, 2005). Another way to encourage a sense of
empowerment is to focus on social justice (Sabik & Tylka, 2006; Russell-Mayhew, Stewart, &
MacKenzie, 2008), for example, Russell-Mayhew et al. suggested the possibility of
conceptualizing eating disorders as a social justice issue that women with eating problems can be
involved in addressing.
In addition to addressing empowerment, a feminist approach may include deconstructing
and understanding dominant views about women, gender roles, and equality, and helping women
to develop their own sense of self rather than one that is largely influenced by external forces
(Yokoyama, 2007). Accentuating their personal strengths and attributes may be one way to
begin to develop this sense of self and encourage women to live authentically as opposed to
according to dominant perspectives. In addition, reducing the use of labels may be one way to
minimize the pathologizing impact of the dominant culture (Burns, 2004). Consequently,
another idea for use with this group program is to have the participants self-define and name
their problem, rather than ascribing or imposing a label.
Deconstructing the women’s experiences in the context of the dominant culture can also
create the opportunity for women to access awareness of other qualities and perspectives rather
22
than only those associated with the eating disorder or dominant views (Black, 2003). For
example, ideas about beauty and women, about what it means to be a mother or daughter, and
these sorts of gendered ideas can be explored and deconstructed (Scott, 2008). This exploration
can provide enhanced awareness and understanding of varying perspectives rather than the
traditional normative and oppressive messages that may be dominant. In addition, women can be
empowered to make the personal political and learn about ways to effect and challenge dominant
societal messages related to their issues (Cummins & Lehman, 2007; Lalande & Laverty, 2010;
Russell-Mayhew et al., 2008).
Before moving on to discuss perspectives and approaches from narrative therapy it is
important to note a useful caution in working from the feminist perspective, which is that,
depending on the client’s cultural ideals and worldview some of these ideas and ways of working
may need to be adjusted (Cummins & Lehman, 2007). For example, Cummins and Lehman
noted that some Asian women may have a belief that the therapeutic relationship should be a
hierarchal one in which the therapist is the expert. This is contrary to the feminist way of
working which involves a collaborative relationship where power differentials are minimized.
This type of difference should be taken into consideration with individual clients to determine
which way of working could best suit their needs and worldview. In general, these types of
cultural issues and individuality among clients must be taken into consideration when
implementing any approaches. This feminist idea of an equal relationship is compatible to
seeing the client as expert of their life, which is a strong central tenet of narrative therapy (White,
2007); that is, that allowing the client to make use of their own knowledge, skills and what will
best suit their life is optimal from a narrative therapy stance.
Eating Disorders and Identity from a Narrative Therapy Perspective
23
In narrative therapy, the client is viewed as the expert of her problem and life, while the
therapist is knowledgeable of therapeutic interventions. In consideration of the client’s views as
central to the therapy process, narrative therapy is based on the idea of multiple realities and
subjectivity rather than one objective truth (Lee, 2004; White, 2007). Accordingly, the focus in
therapy for eating disorders is the sense that one makes of their eating problem (Lock, Epston,
Maisel, & deFaria, 2005). In addition, narrative therapists view eating disorders from a
contextual perspective where political, historical, and sociocultural factors are considered (Lock
et al., 2005). For example, dominant western perspectives of thinness as beauty and the value
placed on self-discipline and control, as well as one’s own personal history would be considered
in how they experience their problem. Similar to the perspective of feminist theory, narrative
therapists also believe that the eating disorder may be used to achieve a sense of control, desired
trait of beauty, or feelings of self-worth. In addition, narrative therapists also focus on the eating
disorder as helping one to cope with other challenges, such as, low self-esteem, trauma,
relationship issues, perfectionism, a desire to please others, and so on (Maisel et al., 2004).
Essentially the eating disorder as a coping mechanism could serve a variety of purposes which
should be considered on an individual basis.
Also similar to feminist perspectives, narrative therapists believe that dominant discourse
can negatively impact someone with an eating disorder. For example, being labelled with all
encompassing diagnoses such as bulimic and anorexic (Weber et al., 2006) may have serious
implications for the individual. Lock and colleagues (2005) stressed that sociocultural context,
dominant messages, and language are major contributing factors to a person taking on an eating
disorder as their identity and that this can be related to (unseen) power differentials. The view
these narrative theorists present is that power contributes to what we come to understand as good
24
or bad; that is, power sets the standard for a universal truth. In other words, if the dominant and
powerful message is that women are failures if they have large bodies or do not meet beauty
standards, then women may internalize this message and identify as bad or failures if they feel
their bodies do not meet the standard set by power. Furthermore, this may encourage eating
disorder behaviours in order to identify with the dominant ideal.
In such power contexts, eating disorders can become one’s sense of worth; that is, the
only thing the person can be good at (Maisel et al., 2004). For example, if they are losing weight
they may view themselves as successful or as having self discipline. Conversely, if they do not
succeed in losing weight this can then confirm an identity of low self worth. Similarly, the
dominant message may be that women should care for others first and should not make
themselves a priority. Therefore if a woman chooses self care over care for others, this may
clash with the dominant message in power, potentially contributing to negative identity feelings.
Likewise, our Western culture promulgates the values of self-discipline and individualism
(Brown, 2007). It follows then that women may unwittingly try to achieve this self-control and
independence (through an eating disorder) and without it, feel inept based on societal messages
and norms. Brown also reflected on how power differentials contribute to problem development
and that “narrative therapy challenges the unexamined, taken-for-granted, everyday assumptions
that often shape limiting stories of the self through the process of re-authoring identities” (p.
108). Contesting these messages is presented as one way to create space for other truths and
possibilities (Lock et al., 2005). Challenging these messages can include deconstructing how
these norms came to be and having conversations about oppression, which is similar to the idea
of understanding the impact of institutions of society from a feminist perspective. Narrative
therapy aims to challenge dominant Western cultural assumptions and to externalize problems in
25
order to create opportunities for other stories of self to emerge (Brown, 2007; Maisel et al.,
2004).
As mentioned earlier, in addition to issues of power, narrative therapists generally take
into consideration one’s own context or personal history and how it may have impacted problem
development. As such, narrative therapists believe that people enter counselling at a time when
their lives are saturated or overtaken by the problem story (White, 2007). People’s problems
take over to the extent that the problem can become the only identity they know. The idea of reauthoring identities then, involves narrative therapists working with clients to create
opportunities to examine other aspects of self and therefore connect with alternate or preferred
identities (White, 2007). This is a central tenet in working from a narrative therapy perspective.
Potential Approaches from a Narrative Therapy Perspective
Narrative therapists believe that the person is not the problem but that the problem is the
problem (White, 2007). This statement in itself allows for identities beyond the dominant
problem story. Narrative therapists suggest externalizing the problem and deconstructing
problem language so that the problem can be seen as separate to the individual rather than all
consuming (Maisel et al., 2004). It is through this effort that the narrative therapist can then
work with the client to begin to focus on what is important in their lives, such as, their values,
hopes, and dreams, so that future client actions can be taken in line with these factors as opposed
to the problem.
Through externalizing conversations, narrative therapists aim to have the client
experience separation from the problem so that the problem is not experienced as all consuming
(Maisel et al., 2004). Externalizing conversations include asking the client questions about the
problem and its effects on their life and relationships, and then having clients take a position on
26
whether or not this is okay with them and why or why not (White, 2005). Discussing the
problem in such a way can promote the objectification of the problem as separate to the
individual. This “space” from the problem can then create the opportunity for other aspects of
self to emerge. Consequently, this can be an effective initial approach in helping clients to
reconnect with a positive sense of self that is not dominated by the problem.
In a narrative therapy group intervention study that included 7 participants with an eating
disorder and depression, participants reported that activities and conversations related to
externalizing the problem were helpful in creating space for their non eating disorder identity
attributes to come to the surface (Weber et al., 2006). Externalizing practices in the group were
shown to help the women move away from the all encompassing identity of anorexic or bulimic.
Participants expressed satisfaction at the realization that they are not their eating problem and
developed more value for themselves through the externalizing processes. In addition to these
benefits of externalizing, there are also some limitations to consider in regards to the use of
externalizing practices. For example, White (2002) cautioned that externalizing practices may
not be appropriate for people experiencing personality disorder or issues with dissociation
because externalizing could heighten symptoms of these problems. Consequently, as with any
therapeutic intervention, counsellors must assess and consider each individual client situation
prior to applying specific interventions.
Weber et al. (2006) also stressed the impact of language and dominant discourse on the
person being consumed by the eating disorder identity. For this reason, narrative therapists use
client language in a positive way to address problems. For example, asking clients to name their
skills and qualities when they have had success managing the problem can be helpful. Since
narrative therapists consider identity issues in eating disorders partly related to the context of
27
pathologizing language and dominant discourses, another way to create the opportunity for a
more positive self identity to emerge is to deconstruct dominant messages with clients so that the
contextual is better understood (Lock et al., 2005). Connecting such problem experiences and
feelings to western societal messages rather than to personal failures can contribute to the
experience of other possibilities in terms of how one views oneself. For example, if one is able
to recognize the thinness ideal as unattainable, this might reduce their feelings of failure and
offer an opportunity to explore other personal qualities that they value.
Brown (2007) suggested deconstructing ideas of control and power and how women
might be using their bodies to express these ideals. In deconstructing these ideas, conversations
about empowerment can begin to take place so that women are encouraged to experience a sense
of agency in managing their situation and finding healthy ways to experience empowerment.
Lock et al. (2005) confirmed the idea of valuing clients as experts of their own lives and
discussing their knowledge and skills as one way to explore client strengths and accentuate their
sense of agency and therefore personal power. Narrative perspectives encourage personal
agency, both for action within one’s own life and for social action (Maisel et al., 2004; White
2007). This can be likened to empowerment and social justice from a feminist perspective.
In addition to externalizing conversations and deconstructing dominant messages,
narrative therapists also look for unique outcomes as a way to accentuate personal strengths and
resources (Corey, 2005; White, 2007). Unique outcomes are times when clients can minimize
the problem or its effects in their lives and they feel they have an upper hand over the problem
(White, 2007). By discussing unique outcomes with clients, the narrative therapist can begin to
have conversations about clients’ strengths, characteristics, and resources that have allowed them
to have some success in resolving their problem (Brown, 2007; Weber et al., 2006; White, 2007).
28
Furthermore, a narrative therapist may focus on what the unique outcome can contribute to the
clients’ knowledge about their identity, for example, what their unique outcome actions indicate
about what they value (Jasper, 2007; Maisel et al., 2004). For example, a woman with anorexia
may eat cookies that her daughter baked for her even though this is a challenge. This may
suggest that the woman values her mother-daughter relationship. These types of narrative
therapy inquiry allow for a focus on other aspects of self, which are healthy alternatives to the
problem story. In summary, these unique outcome experiences pave the way for re-authoring
stories of peoples’ lives and self-understanding, which can help them to reclaim a sense of
identity that is not dominated by the problem (White, 2007). I will now review the literature
related to Adlerian perspectives on identity and eating disorders as well as potential approaches
from an Adlerian perspective.
Eating Disorders and Identity from the Adlerian Perspective
Adlerian theory is a holistic approach that considers social implications, familial,
cognitive, and biological factors with respect to counselling and people’s problems. Belangee
(2006) applied Adlerian theory to work in the field of eating disorders and acknowledged that the
use of Adlerian theory approaches for eating disorders have not been largely studied. However,
three overlapping themes emerged from my review of the limited Adlerian literature in respect to
eating disorders and identity. These were (a) having an identity of low self worth and the desire
to be special which could be coped with through maintenance of the eating disorder, (b) one’s
subjective reality (lifestyle) is apparent through the eating disorder as the eating disorder serves a
purpose, and (c) a feeling of not belonging is associated with eating disorders (Belangee, 2006;
Belangee, 2007; Marshall & Fitch, 2006; Strauch & Erez, 2009). I will briefly summarize these
three themes below.
29
Adlerian theorists propose that people generally strive for significance and superiority
(Corey, 2005) and that the eating disorder can be a way to cope with inferiority issues (Belangee,
2006; Marshall & Fitch, 2006). This is similar to the feminist and narrative therapy ideas
suggesting that the eating disorder can offer one a sense of success and worthiness from an
identity perspective. Belangee proposed that feelings of inferiority in those with eating disorders
may stem from feeling that one can not measure up or compare to others. This is also a similar
view to that of narrative and feminist perspectives that consider dominant sociocultural
influences on eating disorders.
The second idea emerging from the literature on Adlerian theory and eating disorders
relates to lifestyle. Lifestyle, from an Adlerian perspective, is considered to be the way one
organizes and makes sense of their life and essentially includes goals, purposes of life, and
actions within it (Corey, 2005). As such, in understanding lifestyle themes one can learn about a
person’s identity and possible reasons for maintaining the eating disorder (Belangee, 2006;
Marshall & Fitch, 2006). Furthermore, Belangee (2007) noted that an eating disorder may
represent a woman’s view of herself. For example, as mentioned earlier, the eating disorder may
serve the purpose of offering a woman feelings of success or control, a sense of specialness, or it
may offer a way to cope with life’s challenges. In addition, Strauch and Erez (2009) shared
examples of how anorexia can be all consuming and take over all aspects of people’s lives
including their identity.
The third idea stemming from the Adlerian literature relates to social interest, which, in
the context of Adlerian theory is described as “…striving for a better future for humanity”
(Corey, 2005, p. 98). This idea of social interest is similar to the idea of the personal is political
in feminist theory (Lalande & Laverty, 2010) and linking to a greater struggle in narrative
30
therapy (Maisel et al., 2004). I will discuss this further in the next section of the paper, however
from the Adlerian point of view, not only is contributing to humanity important, but finding a
way of fitting in and feeling a sense of belonging are also crucial to human development
(Belangee, 2007). An important consideration in this regard is that people with eating disorders
can be self focused versus community focused, which can take away from their ability to
participate in social interest activities (Belangee, 2006).
Adlerian therapists are also considerate of how people’s contexts affect them and believe
that behaviours can only be understood in relation to people’s environments (Belangee, 2006).
This too is similar to notions from narrative and feminist perspectives that consider sociocultural
contexts as contributing to one’s identity and problems. I have begun to note many similarities
across the three perspectives and in the next section, following my description of potential
approaches from an Adlerian viewpoint; I will summarize these similarities and note major
differences to be considered.
Potential Approaches from an Adlerian Therapy Perspective
In consideration of the Adlerian ideas related to eating disorders many opportunities for
working with clients from an Adlerian perspective arise. Marshall and Fitch (2006) stressed the
need to treat the person as a whole rather than simply treating eating disorder behaviours and
symptoms. This attention to the person as a whole allows for a focus on social factors which is a
common approach presented in the two previous theories. By focusing on contextual
components of eating disorders, counsellors can move away from assuming that the problem is
entirely an individual issue and thereby help to reduce shame and blame in individual clients.
This reduction in shame and blame for the problem can consequently contribute to the
opportunity to focus on alternate (more healthful) aspects of self, which is in line with the
31
holistic approach of Adlerian therapy. In addition to understanding the context of the problem
for each individual, promoting social interest would be important in Adlerian centered work. For
example, counsellors can encourage clients to engage in advocacy activities, volunteer activities,
and related events. These activities can contribute to one’s sense of empowerment and
belonging which can add to a positive identity.
Working with clients on developing or reconnecting with a more positive identity through
the use of early recollections and current day reconstructions can also be helpful (Strauch, 2007;
Strauch & Strauch, in press). Early recollections (or memories) denote clients’ self stories or
identities (Corey, 2005; Hester, 2004). Strauch proposed altering early memories and even
current day events (Strauch & Strauch, in press) through collaborative story writing, in order to
create healthier messages about the way clients would like their lifestyle to be. In this way,
altering unhealthy messages that may be dominating the client, to more positive ones with a
means of rehearsing these messages, may be helpful in assisting the client to challenge and
improve feelings of inferiority as well as begin to alter lifestyle themes to those which are more
healthful and helpful (Strauch & Strauch, in press). Marshall and Fitch (2006), from an
Adlerian perspective, explained this as altering basic mistakes when it comes to eating disorders,
for example, the comment I must be thin to be successful would be a basic mistake that one
would want to alter to align with a more healthful perspective. Similarly, Corey (2005) stated
that in Adlerian therapy, counsellors encourage clients to act as if they were already living the
changes they want to make, as one way to promote the change. The method proposed by Strauch
and Strauch allows for this encouragement through the rehearsal of collaboratively written
stories, which reflect the identity factors clients feel are in line with their current healthier goals.
Within these stories client strengths can be reinforced, further contributing to a sense of
32
empowerment and positive identity. Similarities between stories and memories in Adlerian and
narrative therapy have been noted by Brown et al. (2008) and Hester (2004). This similarity as
well as some differences will be reviewed in the next section.
Summarizing the Similarities and Differences in Perspectives and Approaches
Similarities and differences in perspectives. Several similarities and some differences
among how theorists from feminist, narrative, and Adlerian perspectives view eating disorders
(and its relationship to identity) have been discussed in this project and I will provide further
synthesis. A central tenet of all three theories is that context should be reflected on, when
considering how eating disorders are developed and maintained. However, differences exist
within this contextual view. For example, Adlerian theory focuses more on familial context
although also acknowledges other more global sociocultural influences. Narrative therapists also
consider family dynamics, however feminist and narrative theory focus more on power
imbalances, dominant views, and dominant language as contributing to eating disorders. This
contextual view that is espoused by all three theories funnels into the idea that an eating disorder
can be used to feel a sense of power, control, specialness, belonging, or worthiness, albeit a false
or misleading sense of power, control, specialness, belonging, or worthiness.
In other words, the eating disorder serves a purpose of coping with the contextual issues
involved for that particular individual. For example, I worked with a client recently whose
eating disorder started when she began to notice her father was disappointed with his life and she
felt responsible for this. She described the eating disorder as providing a way to cope and
distract from this difficult emotional response to her father’s situation. In this way, one can see
how the eating disorder can take over and consume one’s identity as it becomes very important
to maintain this coping mechanism. Additionally, the eating disorder can provide a (false) sense
33
of what the person may feel they are missing, for example, a feeling of control or a sense of
worthiness. It is important to note that this sense of worthiness that may be found through the
eating disorder does not entirely counteract the unworthiness the client may really be feeling.
However, the eating disorder offers one way to partially cope or compensate for this sense of
unworthiness. For example, this same client mentioned above, commented on how she defined
herself by the size she wore and how fitting into small clothing made her feel happy and
successful. We are currently working together to improve her confidence, ability to cope, and
sense of control. However, temporarily (and not likely consciously) the eating disorder
provided a way to cope with the insecurity and sadness feelings she was experiencing. Not only
can eating disorders provide a seemingly positive sense of identity to women, but it can also
contribute to a negative view of oneself.
Each of the three theoretical perspectives provides a similar view of how the eating
disorder can provide a negative identity of oneself. For example, all three similarly propose that
if one does not fit in with societal ideals and dominant views or if one “fails” at eating disorder
behaviours, they may come to see themselves as a failure. In addition, narrative and feminist
theorists consider how dominant and pathologizing language related to eating disorders can
contribute to a negative view of oneself, for example, using all encompassing language such as
anorexic or bulimic. Adlerian theorists on the other hand consider dominant sociocultural views
to a lesser extent. Though, Adlerian theorists take into consideration how personal faulty beliefs
can influence a negative view of oneself. For example, someone might hold the belief that
thinness equals happiness, and so if they are thin they will be happy; however, when this is
unattainable it can reinforce negative feelings towards oneself. In summary, all three theories
contain premises about how an eating disorder can impact and take over one’s identity.
34
Another common thread among these three theoretical perspectives is emphasis on social
justice and a sense of community or social interest. The importance of relationships, social
engagement, and social justice activities on positive identity awareness has been documented
from all theoretical perspectives (Belangee, 2007; Lalande & Laverty, 2010; Maisel et al., 2004).
For example, from an Adlerian perspective it is noted that people generally want to fit in, and
being a part of one’s community or family in a healthful way can support this sense of belonging.
Feminist and narrative theorists also believe that engaging in community and social justice can
be helpful to those with eating disorders (Maisel et al., 2004; Russell-Mayhew et al., 2008). In
summary, there are several similarities (and some differences) across the three theories. This
leads into the next section where I synthesize similarities and differences in potential approaches
from the three theoretical perspectives.
Similarities and differences in approaches. Firstly, it is important to note that some of
the foundational tenets of these three theories are similar. For example, each theory has a core
value of upholding the therapeutic alliance. Theorists practicing from any of the three theories
are concerned with developing a collaborative respectful relationship built on trust, in which
power differentials are minimized (Corey, 2005). Another central similarity is in relation to the
idea of multiple realities. For example, Adler believed in a subjective reality (Corey, 2005),
which is congruent with feminist and narrative therapy ideas that there is more than one
universal truth (Lalande & Laverty, 2010; Lock et al., 2005; White, 2007). This perspective
allows for the client to be placed at the center of the relationship and as expert of their
experience, regardless of which of the three theories one may be working from. In addition to
these foundational tenets about ways of working with clients, there are also similarities and
differences related more specifically to interventions for eating disorders.
35
Noting similarities in encouraging social and community engagement, social justice
activities are potential interventions that are similar across the three theoretical perspectives.
Women with eating disorders can be encouraged to engage with their social communities
(including friends and family) both from a perspective of gaining social support, as well as
contributing to their communities. In terms of social justice, this could include work specifically
related to eating disorders or other areas. For example, social justice activities like, educating
people on the sociocultural influences contributing to eating disorders could be one activity that
clients find beneficial. The effects of participating in social engagement and other social
activities could include positive implications for identity in several ways. For example, positive
connections and relationships with others could be fostered and a sense of empowerment can be
established through personal agency. Further, social engagement can provide the opportunity to
engage in activities that are not related to the problem. On the other hand, if engaging in social
justice about eating disorders, there may be the opportunity to reinforce the message that eating
disorders are not an individual problem.
This idea of moving beyond the individual to social connections accentuates the need to
focus beyond eating disorder behaviours and to apply a holistic approach. This includes the
consideration of one’s sociocultural, political, and personal contexts; an approach similar to all
three theories. This consideration of context allows for emphasis on the problem as external,
with multiple influences rather than an individual internal problem. This then can lead to a
reduction in shame and blame and encourage other more positive aspects of the client to emerge.
Within this approach, one could synthesize the three perspectives and consider deconstructing
dominant messages both from a global sociocultural perspective as well as on a personal level.
For example, dominant messages found in broader social contexts and in more personal familial
36
roles can be explored. Deconstructing these messages can help one to further understand the
influences of the problem as beyond them as individuals. Adding to this, a counsellor might
consider allowing a person to self-define and name their problem. This begins to address the
issue of all encompassing pathologizing language, which was highlighted in the feminist and
narrative perspectives. These ideas related to context contribute to creating the opportunity for
positive aspects of the client to emerge; those that are not associated with the problem identity,
but rather a preferred identity or view of oneself.
Along these same lines, working from a feminist perspective, counsellors can work with
women to help them reinterpret symptoms as healthy responses to their subjective and contextual
experiences (Lalande & Laverty, 2010). This idea is also supported by the literature on narrative
therapy (Lock et al., 2005) and through the Adlerian reference that the eating disorder serves a
purpose (Belangee, 2006). In summary, the eating disorder can be sustaining for a woman, for
example in providing a particular identity or by helping her to cope. Consequently, to focus only
on dieting and other superficial factors or overt behaviours in recovery could reinforce the eating
disorder identity at the expense of losing opportunity for positive identity awareness.
Another similarity to note relates to accentuating client strengths. From a feminist
perspective, a counsellor may want to consider helping clients to develop a sense of
empowerment related to their life and in relation to overcoming the problem. This is similar to
the idea of emphasizing personal agency (White, 2007) from a narrative therapy perspective.
Although I have not found specific mention of encouraging empowerment in the Adlerian
literature, there are many similar ideas presented, such as encouraging a sense of worth and
coping with problems directly, rather than through the eating disorder (Belangee 2006).
Empowerment can be reinforced then, through ensuring there is attention drawn to client
37
strengths, skills, and positive qualities. Narrative therapists also present the idea of having
clients name their own skills, qualities, and knowledges (White, 2007) in an effort to use
language in a positive way and to further encourage this sense of empowerment or personal
agency.
In addition to this idea of empowerment, one final similarity to note is that all three
theories have a similar perspective on reflecting on purpose in one’s life. For example, narrative
therapists are interested in what is important to clients, why they make certain decisions, and
what these decisions indicate about their intentions, values, and hopes (White, 2007). For
example, a woman with anorexia and severe restricting behaviour may eat cookies baked by her
child even though it is difficult. A narrative therapist might be interested in understanding what
it was that was important to the woman in taking this action and what her hopes and intentions
were in relation to eating the cookies (and her relationship with her daughter). This in turn can
lead to the understanding of positive identity factors for this individual. Feminist theorists also
support the idea of helping clients understand what is important to them and accentuating a sense
of purpose for their life (Yakushko, 2007), and from an Adlerian perspective it is believed that
one’s actions coincide with a sense of purpose or intention in achieving a goal (Belangee, 2006;
Marshall & Fitch, 2006). This similarity leads me to consider an approach where one’s sense of
purpose, intentions, or hopes for their future can be emphasized. This can encourage current and
future decision making to be in line with these (healthy) goals and values, rather than with the
problem story goals. In addition to these similarities and differences in approach, there are some
other differences that may be relevant to the development of this program.
Specifically, narrative therapists use externalizing conversations in which the problem is
objectified in order to create separation from the problem. This is done in addition to
38
deconstructing dominant messages. Feminist therapists also work to deconstruct dominant
messages that may be influencing the problem. These specific techniques (externalizing and
deconstructing dominant messages) serve to encourage alternate perspectives on the problem.
Adlerian therapists make use of the idea of basic mistakes or faulty beliefs to encourage alternate
perspectives. For example, Adlerian therapists will help clients understand their erroneous
cognitive beliefs that are contributing to the problem and then help them to alter these to be more
healthy and supportive of their goal. In summary, theorists working from each of the three
theories may encourage clients to learn alternate perspectives about the problem. From each
theory this can be done in similar ways, however there may be more emphasis on particular
techniques over others based on the theory being used.
Another difference can be found in the use of stories. Both Adlerian and narrative therapists
are interested in clients’ stories and the possibilities of re-writing these stories (Hester, 2004),
however in different ways. Narrative therapists (as mentioned earlier) may help clients to reauthor stories based on their lived experiences, while Adlerian therapists may focus on client
goals in re-authoring stories regardless of whether or not there are existing stories representing
these goals. In other words, narrative therapists are interested in existing stories, while Adlerian
therapists will make use of created or imagined stories, whether or not they have occurred in
reality (see Approaches from an Adlerian Perspective for further information).
In summary, the following similar themes related to perspective and approaches from the
three theories will be considered in planning the group program entitled, Rediscovering who you
are: Beyond the Eating Disorder Identity: Themes related to the three theoretical perspectives
include (a) the eating disorder can encourage a way of seeing oneself (identity factors), such as,
feelings of being successful, a failure, or special, (b) sociocultural contexts including language,
39
dominant views, power, and more personal contexts influence the way people view themselves,
and (c) the eating disorder can take over because it serves a purpose, such as, providing a sense
of identity or helping one to cope with life challenges and issues. Themes related to approaches
from the three theoretical perspectives include (a) the use of a collaborative working alliance that
is client centered, (b) encouraging social justice, social engagement, and community or
relationship focused activities (to encourage empowerment and social support), (c) focusing on
contextual factors and not simply behaviours or symptoms, (d) encouraging an alternate
perspective on the problem, (e) finding ways to reflect on more positive aspects of self that can
also be linked to purpose, intentions, values, and hopes, and (f) focusing on strengths, such as,
qualities, skills, and knowledge to further support an identity beyond the problem and also to
encourage a sense of personal agency and empowerment. These similarities in approaches were
considered in designing the 8-week program (Chapter 4). Furthermore, these similarities allow
for the reasonable integration of these theories.
Making the Case for an Integrated Approach
Psychotherapy integration (utilizing more than one pure theoretical form of therapy with
a client) has been increasing over the past decade. Norcross and Goldfried (2005) shared the
perspective of several authors on the subject of psychotherapy integration. In general, they
viewed psychotherapy as essential and important, and acknowledged the limitations of using just
one theory when working with clients. About one quarter to one half of psychotherapists are
now practicing an integrative form of psychotherapy and there have been encouraging results
suggesting positive outcomes with the use of an integrative approach (Norcross, 2005). In
particular, using an integrative approach can be helpful in complex cases as it offers alternate
options to pure forms of therapy, especially when these pure forms are not useful. In other
40
words, psychotherapy integration allows for alternate forms of therapy to be considered as
opposed to one form being viewed as “right” for a particular disorder. With regards to this group
program, the facilitator may not have individual details about participants’ learning styles and
issues. Therefore, by offering variation in the weekly activities (based on various theories), it is
my hope that each participant can find something of value.
Essentially, in learning various forms of therapy counsellors are often inherently
integrative and what informs the choices made in terms of working with someone involves the
individuality of each client (Richert, 2006; Stricker, 2009). For example, my own work has been
informed by feminist, narrative, Adlerian, and cognitive behaviour theory ideas. How I
implement aspects of these theories is largely dependent on the client before me and what I (and
she) believe could be most helpful to her. Richert supported this way of practicing integration by
demonstrating how other therapies could be used within a narrative framework, based on how
clients presented their problem. For example, if through the client’s stories, the therapist sees
that the client describes their problem as being centered individually on their thoughts and
experiences, then integrating a related therapy such as cognitive behaviour therapy, could be
most useful for such a client.
In regards to integration in the work of eating disorders, it is important to acknowledge
the complexities of eating disorders as well as the challenges with recovery as discussed earlier
in Chapter 1. The complexity of eating issues suggests the need to consider multiple and
integrated approaches based on individual client needs. The following information is a summary
of the literature related to integrating theories in work with eating disorders.
In a survey of 268 professionals working in an organization that treats people with eating
disorders, Simmons, Milnes, and Anderson (2008) reported that 21.6% of the counsellors used
41
an eclectic approach in counselling individuals with eating disorders. This was the second most
common approach, while the most common was cognitive behaviour therapy at 36.6%.
Simmons et al. further noted that the reasons for not using manual based single theory
approaches was related to the professionals considering this too rigid and constraining for the
types of people they encounter and treat. Although the authors seemed concerned that manual
based empirically supported treatments were not being used, I believe it is important to note that
they found that professionals newer to the field were using them, while those more experienced
were not. This could possibly suggest that empirically supported manualized treatments have
been found not be the most effective approach in some practical settings. This discussion
however, was beyond the scope of the particular survey studied.
As an alternate to an eclectic or one theory approach, Brown and colleagues (2008)
reflected on eating disorders and traditional eating disorder treatment perpetuating an
individualistic view of eating disorders and instead suggested combining feminist and narrative
perspectives as an alternate method of treatment. The authors provided a theoretical foundation
for combining these two theories in the treatment of eating disorders. For example, they
suggested combining gender related and contextual factors from a feminist perspective with the
idea of stories of self contributing to identity from a narrative perspective and including a focus
on a woman’s sense of agency in overcoming the problem. The authors applied this combined
approach to work with a 23 year old woman who had alternating bulimia and restrictive patterns
of eating. They found that there was an improvement in the eating disorder symptoms for this
woman. A wise future direction would be to test the outcomes of such an integrated approach
with larger and more varied samples.
42
In a recent larger study, 196 disordered eating patients received an integrated outpatient
treatment approach which was shown to be successful (Schaffner & Buchanan, 2010). The
program included individual therapy, group therapy, family therapy, cognitive behaviour theory,
psychodynamic theory, and recent evidence based treatments. In addition, addressing unique
client preferences, characteristics, and culture were a consideration. On average, participants
(age 13-51) received treatment for 14 weeks and had significantly improved eating disorder
symptoms as well as improved anxiety and depression symptoms. Schaffner and Buchanan
concluded that integrating information from research to fit client unique needs can be helpful in
treating eating disorders, which are known to be complex problems that require an integrated,
flexible, and multimodal approach to treatment.
In another integrative study, Cook-Cottone, Beck, and Kane (2008) combined cognitive
behavior theory, dialectic behavior theory, positive psychology, and body focused methods (e.g.,
yoga). Twenty-four women with anorexia or bulimia completed the group program and
improvement was evident related to body satisfaction, reduced interest in dieting, and less fear of
weight gain. However, there was not significant improvement related to the reduction of bulimia
symptoms. A limitation of the study was that there was no control group; however, the
preliminary results indicate potential for this type of integrated program.
In summary, I have provided literature supporting the use of psychotherapy integration
both from a general perspective as well as related to eating disorders. Employing this knowledge
as well as that related to eating disorders and identity will contribute to the development and
delivery of this group program in which I will integrate feminist, Adlerian, and narrative
approaches. The following is an example of how an integrated approach could be applied to
working with Lisa from the vignette presented in Chapter 1.
43
Lisa is consumed by the eating problem, for example, she is thinking about food and her
body obsessively. A counsellor might choose to externalize the eating problem from a narrative
therapy perspective. This will start to encourage the feeling of Lisa being separate from the
problem. Within the externalizing conversation, deconstructing the problem will also be
important. This deconstruction of the problem can be used to explore norms, dominant messages,
and gender roles from a feminist perspective. Furthermore, helping Lisa to identify the problem
as a coping mechanism can be helpful. This idea of the problem as a coping mechanism is
central to all three theories (feminist, narrative, and Adlerian). Lastly, in consideration of
Adlerian theory, Lisa may be (unwittingly) using the eating disorder to feel significant and
worthy. For example, she highly valued the complement she received from her co-worker about
her appearance. Helping Lisa to develop her sense of worth based on other personal qualities
and characteristics, such as, her sense of adventure, advocacy skills for children, and
determination may allow her to let go of using the eating disorder in this regard. This
intervention of focusing on personal qualities is a similarity found in all three theories. In
addition, examining (and challenging) faulty beliefs that may be contributing to Lisa feeling
unworthy could also be helpful. For example, the idea of needing to be thin to be attractive is
one that could be challenged and balanced. This intervention of examining faulty beliefs comes
from the Adlerian approach. In summary, the three theoretical approaches can be integrated in
working with Lisa.
The Use of a Scrapbook
In addition to combining the three theoretical perspectives within the group program
activities, there will also be a scrapbooking component. Specifically, each participant will create
a scrapbook of their weekly experiences and learnings from the group activities. The main
44
reason for creating the scrap book is to allow the opportunity for the participants to sustain their
learning and experience in a positive way. Scrapbooking fits with narrative therapists’ interest in
practices that allow for change to be remembered and accessed beyond counselling sessions
(White, 2007). It is my hope that the scrap book will be one way this is provided for through the
group program.
Group Process and Suggested Structure of the Group
Group program development must integrate the use of group theory and research in order
to be successful (Wheelan, 1997). In this section, I focus on the most relevant aspects of group
theory to provide a suggested structure for the group. These aspects are related to the use of an
open or closed group, the size, frequency, duration of meetings, and whether to have a
homogeneous or mixed group. Before I address these issues, it is important to repeat that the use
of group programs in work with eating disorders seems to be a common practice that involves
many benefits, for example, the relational aspect of group work contributes to reducing shame,
reducing isolation, feeling supported, and encouraging hope for recovery (Corey, et al., 2010;
Weber et al., 2006).
Open versus closed group. There are pros and cons to having an open group, as there
are pros and cons to having a closed group. An open group involves people joining and leaving
the group beyond the initial session (Corey et al., 2010). This can offer interaction with a greater
variety of people; however it can also result in poor group cohesion (Corey et al., 2010). A
closed group on the other hand, involves participants staying in the group until it ends and no
addition of new members beyond the first session (Corey et al., 2010). As noted above, group
cohesion and relational aspects of groups can be highly beneficial in a group related to eating
disorders (Heenan, 2005; Weber et al., 2006). Subsequently, I propose that this group be a
45
closed group in order to encourage group cohesion and support as much as possible. In addition,
it is difficult to maintain continuity in an open group and the intent of this program is for
participants to build on and accumulate ideas related to (re) discovering their identity.
Size, frequency, and duration of meetings. Corey and colleagues (2010) recommend
an ideal group size of 8 adults, which will allow for all members to participate, be involved, and
encourage a sense of group cohesion. More than 8 participants may not be ideal because there
may not be enough time for all members to participate equally. In addition, although Corey and
colleagues recommend 2 hours as ideal for the duration of each group session, the eating disorder
support centres in my vicinity, where this group would potentially run, only offer group sessions
for 1.5 hours over 8 weeks. For example, Sheena’s Place, Eating Disorders of York Region, and
Danielle’s Place, all in Southern Ontario, only offer 1.5 hour groups. This is likely related to
funding issues. Consequently, since I am likely to facilitate this group program at one of these
organizations I have chosen to develop the program based on these parameters. A benefit of a 1.5
hour group is that participants will be able to remain focused for that period of time. However, it
may be a challenge for the facilitator to manage the time to ensure the proposed content can be
covered. Offering the program over 8 weeks will allow for the content to be spread out and will
allow time for participants to connect with one another. In summary then, I propose an 8-week
closed group program with weekly 1.5 hour sessions, with 6-8 participants in order to maximize
participation and benefits.
Homogeneous or mixed group. An important consideration in work with eating
disorder groups is the various forms of eating disorders and presenting issues. For example,
anorexia symptoms differ from bulimia and binge eating symptoms. This program will not
specifically be addressing the behaviours and symptoms of the specific eating disorders, but
46
rather the idea of developing a positive identity. Consequently, it seems reasonable that a mixed
group could be encouraged. Moreover, underlying issues and contributing factors to eating
disorders are similar across the various types of eating disorders (Polivy & Herman, 2002) and
not everyone with a disordered eating problem fits neatly into the DSM IV criteria (Grave &
Calugi, 2007; Waller, 2008). Consequently, for this group program, a mixed group seems
reasonable.
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CHAPTER 3
Procedures
Steps Involved in the Process of Program Development
This 8-week group psychoeducational program is designed to help adult women with
disordered eating problems to re-discover who they are beyond the eating disorder problem. The
first step I took in developing this program was performing a detailed, current, and critical
review of the related literature. I conducted searches of a number of EBSCO databases (e.g.,
Academic Search Complete, CINAHL Plus, psycARTICLES, Psychology and Behavioral
Sciences Collection, and SocINDEX), a search of on-line books, and hard copy books. Searches
were limited to literature published within the past 6 years. However, at times literature older
than this was accessed because there was not current related literature available, or in an effort to
show the history of relevant information. Search terms included a variety of combinations of the
following: eating disorders and treatment, eating disorders and prevalence, eating disorders and
identity, eating disorders and feminist, eating disorders and narrative therapy, eating disorders
and Adler, identity and feminist, identity and narrative therapy, identity and Adler,
psychotherapy and integration, integration and eating disorders, groups and eating disorders,
groups and benefits, and art and eating disorders. In addition, I also searched references found
within the literature that I accessed and also reviewed the literature I have accumulated on these
related subjects over the past several years.
In addition to these hard copy and online materials, I accessed knowledgeable colleagues,
organization staff, and other related programs for information that could support the intent of this
program. For example, I shared my ideas with the organization lead of Eating Disorders of York
Region to hear her perspective on how such a program could be beneficial to the clients
supported at this particular organization. I also discussed the idea of an integrated approach with
48
a lead staff person at Sheena’s Place in Toronto for further feedback. Lastly, I used my own
knowledge and experience gleaned both from individual work with women with eating disorders
as well as group work with women with eating disorders. I have used this review of the
literature, knowledge transferred through networking, and my own knowledge to develop this 8week psychoeducational program.
49
CHAPTER 4
Specific Product
The work of this final project culminates in the creation of the 8-week group
psychoeducational program, (Re) Discovering who you are: Beyond the Eating Disorder
Identity, which is the focus of this chapter. Firstly, I share information related to recruitment and
screening potential participants for inclusion in the group. Following this, I outline the weekly
activities of the group program, which have been developed in relation to the theoretical
underpinnings and literature review already presented. As noted in Chapter 2, the similarities
and differences found in the literature among the three theories forms the basis of this program
development. I apply the similarities in perspectives and approaches along with unique
interventions of each theory in order to provide a group program that is theoretically sound in
similarity, but also offers the opportunity for different group participants to connect with, or
benefit from, different styles. Essentially, different group members may benefit from different
aspects of the group, potentially maximizing the impact of the program (Corey et al., 2010).
Recruitment
There are several agencies and organizations in Ontario and other provinces that support
the needs of those suffering from eating disorders. These agencies include not for profit support
centres, counselling agencies, hospitals, private practices, and so on. All of these types of
organizations are appropriate places to recruit participants for this group program. In addition,
other health related centres could be appropriate for recruitment, for example, doctors’ offices,
multidisciplinary health clinics, and advertisements in local newspapers. A flyer can be prepared
for posting that includes a summary of the program, target audience, location, and dates
(Appendix A). In addition, the group facilitator can verbally provide information about the
50
program to these organizations so that they can in turn inform their clients. The program is
appropriate for women already working on recovering from their eating disorder as well as those
just beginning the recovery process. Women from either of these groups could benefit from the
program. For example, they may benefit from the group as an adjunct to the work they are
already doing (particularly when that work is focused on eating disorder symptoms) or as a first
step to discovering that there is more to their identity, beyond the eating disorder symptoms and
issues. In this way, this program is honouring of whichever stage of change (DiClemente et al.,
1991) the client may be in. In other words, there is not a focus on change. However,
participants may change (or not) based on their individual experience of the group activities and
processes. Given that there is generally a lot of ambivalence about change in regards to eating
problems, this program can be appealing to people that are hesitant and only beginning to
consider the possibility of change (Blake, Turnbull, & Treasure, 1997).
Screening
Before addressing the issue of screening it is important to note that (as mentioned earlier)
this group will be a heterogeneous group and the intention or purpose of the group is to provide
an opportunity for participants to see beyond the eating disorder in terms of their identity.
Subsequently, there is not a direct focus on “recovery” or changing eating disorder behaviours.
However, the hope is that this program can create the opportunity for participants to consider
alternate actions, values, qualities, and ideas that may be contrary to the eating disorder
symptoms, which in turn could result in a change in behaviours. This was the case in the 10week narrative therapy (heterogeneous) group program offered by Weber and her colleagues
(2006). They informed all participants at the start of the narrative therapy group that there was
no expectation for them to make changes (in regards to their eating problem), but rather the
51
purpose of the group was to explore options and ideas. Weber and colleagues suggested that this
alleviation of the expectation for change may have contributed to the positive outcomes for the
participants. This notion of using the group as an opportunity for exploration has informed the
development of this 8-week group program.
Another narrative therapy underpinning of this 8-week program involves the idea of selfreferral. Participants can self-refer to the program if they identify with having an “eating
problem”. The term eating problem and the idea of self-referral both reflect narrative therapy
tenets that involve the importance and impact of language and subjective reality and meaning
making (Weber et al., 2006). In other words, narrative therapists are interested in how clients
self-describe and define their problems as problems. Consequently, screening for this program
will involve informal means and will be heavily based on potential participants’ subjective
experience, knowledge, and the sense they make of their problem (Lock et al., 2005). Also in
support of self-referral and minimizing the significance of specific diagnostic labels, Waller
(2008) reinforced the idea that many people with eating issues may not fit neatly into diagnostic
groups, yet they too must be considered in treatment planning.
Potential participants will be screened by the group facilitator and should broadly meet a
wide-ranging definition of disordered eating which includes a self-description of having an
eating problem that has significant effects on their life; causing difficulties for them and their
life. The symptoms may include restrictive eating patterns, obsessions with food and body
image, purging, other compensatory behaviours, and or binge eating. This screening will be
conducted over a one hour meeting by the facilitator and will include a discussion of the group
program. The meeting and discussion will be collaborative, with a specific intention to value (in
the spirit of narrative therapy) the participant as expert of their own life and experience (Weber
52
et al., 2006; White, 2007). The facilitator (and potential participant) will be looking for a match
between the participants’ self-described needs and expectations, and the group program goals
and purpose.
During the informal assessment the facilitator will be gathering information from the
potential participant and vice versa. The facilitator will mostly be looking to seek out
information that could support the woman as suitable for the group and vice versa. One of the
main areas of the screening assessment then includes the client’s current situation as she
describes it. From this, the therapist will be listening for any contraindications for inclusion in
the group and will also want to directly enquire about contraindications. These contraindications
may include, complex medical problems, for example, extremely low weight with a BMI less
than 17.6 (Fairburn, 2008), purging more than twice per week, and complex mental health issues,
for example, a recent suicide attempt (Weber et al., 2006) or suicidal ideation. In these situations
the facilitator will explain to the client that the group may not be appropriate at this time as these
other issues should be dealt with as a priority. The facilitator will then ask about medical and
psychological follow up and provide the client with a referral if she does not have appropriate
medical monitoring or psychological intervention. For the other participants that will be joining
the group, medical monitoring and psychotherapeutic intervention can be discussed however is
not necessarily a requirement to join the group. The facilitator can use the screening assessment
as an opportunity to encourage medical and psychotherapeutic follow up however this is not a
reason to turn away a participant who might otherwise not access support again. In my
experience many women struggle to take the first step in addressing an eating problem. Joining
a group can often be that first step. Allowing maximum opportunity for this initial step to occur
could be what is needed to help some women begin the journey to recovery. The fact that this
53
group program is not a therapy group but rather a psychoeducational group for self-exploration is
conducive to women that are just beginning to engage with the idea of potential change. In
addition, those that are already engaged in the change process can also benefit.
During the screening, the facilitator should enquire about how the client heard about the
group and her reason for wanting to join the group at this time. This will allow for a
collaborative conversation about the client’s needs and hopes in relation to what the group may
offer. The facilitator should also enquire about other groups or therapy that the client may have
participated in and have an open discussion about what may have been helpful or not helpful.
This information can then be related to what the client can expect in this 8-week group program.
Learning about the client’s eating disorder behaviours and experience may also be helpful in
initiating a conversation about how the eating disorder may be consuming the participant’s
identity. In addition, the therapist can begin to have a conversation about positive identity
attributes, for example, about the participant’s strengths and resources. This will set the stage for
what will take place in the group program and will encourage a positive feeling for the potential
participant in starting this program. Essentially, starting from this screening process the
participant will be learning and practicing engaging with other aspects of self, beyond the
problem.
In summary, the screening assessment is informal, broad, and encouraging of
participation and a collaborative relationship. The intention, in line with narrative therapy ways
of working is to encourage the women to engage in the group and to offer maximum opportunity
for this as long as there are no specific contraindications (e.g., complex medical or mental health
issues). Once eight women have been selected, others that are appropriate can be informed of
the next group start date. All those interested in participating are required to sign an informed
54
consent noting their understanding and appreciation of what the group entails and any potential
risks (Appendix B). In addition, participants will be asked to complete an evaluation form on the
last group session (Appendix C).
Weekly Sessions
Session One: Beginning to Separate from the Problem
Session theme. This first session involves an exploration of a variety of contextual
factors that may have contributed to the eating problem, for example, personal history,
experience, western dominant messages about weight, thinness, self-discipline, control, and so
on. As mentioned earlier, all three therapies (narrative, Adlerian, and feminist) have tenets
related to understanding how context affects individuals and their problems. As such, this first
session involves an integration of all three theoretical perspectives and begins the process of
understanding the problem as separate or external to oneself (i.e., I have a problem as opposed to
I am the problem).
Session objective. The first objective of this first session is to provide an overview of
the group purpose and weekly sessions. In addition, participants will introduce themselves and
can each be asked to share their hopes in attending the group. The facilitator/counsellor will
offer the same information from her perspective, will encourage full participation and
commitment, and will review group guidelines including maintenance of confidentiality. The
counsellor will also provide each participant with a scrap book and starter supplies and will
encourage participants to also bring in their own supplies for scrapbooking (e.g., photographs
and crafts). The facilitator should also request that no fashion magazines (or similar that may
perpetuate the thinness ideal) be brought into the group for scrapbooking, explaining that these
may contribute to the women feeling bad about their bodies. The counsellor will inform the
55
group that scrapbooks can be worked on outside of the group as well and that they will be shared
with the group at the final session.
The second objective for this first session is for participants to consider contextual factors
related to their eating problem. This will be done through discussion, with the intention to
reduce self-blame and a totalizing view of themselves as the illness. This in turn can lead to the
beginning of separating from the problem which may encourage the opportunity to explore more
positive aspects of self in future sessions.
Materials.
•
1 scrap book per participant
•
scrap book supplies, (e.g., tape, glue, scissors, stickers, and other crafts)
Introduction. (15 minutes). Each participant, starting with the facilitator, will
introduce herself and share what her hopes are in attending this 8-week group program. The
facilitator will review guidelines for the group, (e.g., no food to be brought into groups, no
discussion of numbers in regard to weight or sizes, confidentiality to be maintained, taking turns
to speak, participation, connecting outside of the group, etc) and encourage participants to
contribute to setting the guidelines. The counsellor will then provide a brief overview of the
structure and content of each session and again encourage feedback.
Discussion activity, exploring context. (40 minutes) The facilitator will start by
providing a brief overview of how one’s context can affect their perceptions and experience.
Providing examples will be helpful (e.g., hearing or seeing the dominant message that thin equals
beauty may contribute to negative feelings about one’s body if it does not match the ideal). In
addition, the facilitator can lead a discussion about dominant cultural norms and ask participants
to share their own examples and experience of such norms. At some point in the discussion it
56
will be important for the facilitator to include the message that although people are influenced by
their environments, they are able to alter and manage the effects of the environment as active
agents of change within their own lives. This message reinforces the concepts of empowerment
and action, which are acknowledged in all three theoretical perspectives as important to
improving problems.
The facilitator will ask each participant to consider and share some dominant messages
they have encountered and the facilitator will also provide some examples. The facilitator can
raise the ideas of the thinness ideal and dominant values of self-discipline, self-management, and
control. The counsellor will also encourage participants to share how they have encountered
these dominant messages and how they may relate to their eating problem. Part of this
discussion may include the topic of gender roles and expectations (which will also be explored in
week 4). The discussion of gender roles and expectations can be helpful in connecting the
women to one another and may also encourage self-advocacy actions (Koski, 2008).
The facilitator can also encourage a discussion about how some media images may
reinforce particular dominant cultural messages and ask participants to share their views and
perspectives on the impact of such images. The counsellor can then ask each participant to share
something from their own personal history and experience that may have impacted the eating
problem. The facilitator may want to share an example (e.g., witnessing a parent dieting on and
off as a young child).
Scrapbooking. (25 minutes). The facilitator will encourage participants to create the
first page of their scrapbook in which they can depict how they may be (or begin to imagine
themselves as) change agents within the context that the eating problem was developed. For
57
example, a participant may depict herself managing or challenging dominant cultural messages
or self-esteem issues.
Closing. (10 minutes). In closing, the facilitator will ask each participant to share one
new insight or something that stood out for them from the session today.
Session Two: Continuing to Separate from the Problem through an Externalizing
Conversation.
Session theme. This second session will focus on the use of the narrative therapy
technique of externalizing (White, 2007) in order to help participants see the problem as separate
from them. This will continue to encourage the opportunity for other (non-problem) stories of
self to emerge.
Session objective. The objectives of this second session are to encourage participants to
engage with one another and to have participants begin to personify or objectify the problem so
that it can be seen as external to them. The intention is that this exercise can continue to help
participants to reduce shame and self-blame for the problem, thereby continuing to create
separation from the problem. White (2007) wrote that only once the person sees some separation
from the problem can they be in a position to actively change their relationship with that
problem.
Materials.
•
Interview questions (externalizing conversation), Appendix D. (These
questions were created from my knowledge of narrative therapy and based on
the work of Michael White (White, 2005; White 2007).
•
Scrapbook materials
58
Check in. (10 minutes). Each of the rest of the sessions will include a 10 minute check in
before starting the scheduled activities for that session. This will provide an opportunity for each
participant to say a few words about how they are feeling and also serve as an ice-breaker.
Introduction. (10 minutes). The facilitator will discuss the idea of externalizing
conversations and provide examples (examples can be found in the books, Life without Ed
(Schaefer & Rutledge, 2004), Biting the Hand that Starves You (Maisel et al., 2004), and the
website, www.narrativeapproaches.com). Following this the facilitator can encourage comments
from the group.
Activity. (20 minutes). The counsellor will provide each participant with the externalizing
interview questions (Appendix D) and ask participants to get into pairs. Each of the pair will
take turns interviewing their partner as their eating problem (approximately 10 minutes each) by
following the questions provided in the handout.
Discussion. (20 minutes). After the interview is completed, the pairs will reconnect with
the larger group and share how they found this experience.
Scrapbooking. (25 minutes). The facilitator will ask participants to create their next
scrap book page which depicts an image of the personified version of the eating problem, a letter
to their eating problem about what they’ve learned about it, or about what stood out through the
interview process.
Closing. (5 minutes). The counsellor will ask each participant to share a word to describe
their experience in the group today.
Session Three: Beginning the (Re) discovery Process: Connecting with Strengths and
Resources.
59
Session theme. In this session, participants will have the opportunity to explore their
strengths, skills, positive qualities, and resources through the narrative therapy technique of
exploring unique outcomes (White, 2007). As mentioned earlier, helping clients to see their
strengths and access them; that is, to empower clients, is also important to feminist and Adlerian
therapy ways of working. Although a narrative therapy technique is used in this session; the idea
of focusing on strengths and resources is common to all three theoretical perspectives.
Session Objective. The objective of this third session is to encourage participants to begin
to explore other aspects of their identity; those that are not dominated by the problem story
(White, 2005). This will be done through exploring times the person had the upper hand on the
problem, or times when the problem has been less successful in their lives (White, 2005).
Through these explorations, the intention is for participants to begin to acknowledge their
strengths and resources and also to connect them to their identity, for example, their values,
hopes, dreams, and intentions (White, 2007).
Materials.
•
Interview questions (unique outcome conversation), Appendix E. (These
questions were created from my knowledge of narrative therapy and based on
the work of Michael White (White, 2005; White 2007).
•
Scrapbook supplies
Check in. (10 minutes). See session two.
Introduction. (10 minutes). The facilitator will discuss the idea of unique outcomes and
the possibility that even though we may feel dominated by our problem, there are often (even
small) ways that problems are not successful in taking over people’s lives entirely (White, 2005).
This represents the narrative therapy idea that our lives are multi-storied and although people
60
with problems may be dominated by problem stories, there are other more positive or healthy
stories that counsellors can help them to bring about and re-author (White, 2007).
Activity. (20 minutes). The counsellor will provide each participant with the unique
outcome interview questions and ask participants to get into pairs. Each of the pair will take
turns interviewing their partner (approximately 10 minutes each) as their eating problem by
following the questions provided in the handout.
Discussion. (20 minutes). After the interview is completed, the pairs will reconnect with
the larger group and share how they found this experience.
Scrapbooking. (25 minutes). The facilitator will ask participants to create their next scrap
book page which depicts an image of their strengths, skills, qualities, and resources that help
them to (even occasionally) have the upper hand over the eating problem.
Closing. (5 Minutes). The counsellor will ask each participant to share a word to describe
their experience in the group today.
Session Four: Continuing the (Re) discovery Process; Roles, Strengths, and Interests
Session theme. In this session participants will continue to explore and build their
knowledge of their strengths in relation to particular roles and interests they may have in their
lives.
Session objective. Participants will have the opportunity to review the various roles they
play in their lives including activities of interest that they engage in. This discussion will also
provide the opportunity to reflect on connections with others, for example, as a mother, aunt,
sister, etc. This idea of belonging and connecting with others is based in Adlerian theory as
mentioned earlier. Their strengths and preferences in these roles and activities will also be
explored. Part of this exploration involves continuing to build awareness of strengths (as
61
supported by all three theoretical perspectives), but also to deconstruct potentially oppressive
ideas surrounding clients in these roles, for example, related to female gender role expectations
(Brown et al., 2008; Koski, 2008). Consequently, this session also specifically reflects feminist
ways of working.
Materials.
•
Flip chart
•
Markers
•
Blank paper and pen for each participant
•
Scrap book supplies
Check in. (10 minutes). See session two.
Activity. (15 minutes). The facilitator will write the following questions on the flip
chart and review and explain them to participants. Then the facilitator will ask each participant
to respond individually on their own paper.
1) What various roles do you participate in, for example, mother, employee, just being
you, friend, advocate, Ontarian, etc.
2) What activities do you most enjoy, or what are you engaged in when you feel most
passionate, peaceful, or happy?
3) What are your strengths in each of the roles or activities you wrote for question one
and two? It might help to imagine what someone close to you might say are your strengths.
4) What are your own expectations of yourself in these roles and activities? How do they
compare to others’ expectations that you may feel influenced by. Others can include people in
your life and also dominant messages that you may be exposed to, for example, in the media or
from your own ethnic culture.
62
5) What are your preferred ways of being in these roles and engaging in these activities?
What does this say about what is important to you and what you value?
6) Are there factors or people that support your preferred ways of being or strengths in
these roles and activities?
Discussion. (25 minutes). The facilitator will ask people to share their responses and
facilitate a discussion that includes each participant sharing their strengths and values. This
discussion will also involve the deconstruction of any oppressive views that may arise.
Scrapbooking. (30 minutes). The facilitator will ask the participants to create their next
scrap book page to represent their preferred ways of being and values in relation to the various
roles and activities they participate in.
Closing. (10 minutes). The facilitator will ask each participant to share something
they’ve learned about themselves today or something they have reconnected with that they
would like to hold onto.
Session Five: Preferred Ways of Being
Session theme. Preferred ways of being can represent one’s goals and values. In this
session, participants will be asked to consider how their life would be if their values, goals,
hopes, and dreams were a part of their daily experience. This session will mainly reflect the use
of Adlerian ways of working, using the ideas and techniques of reflecting as if (Watts, 2003;
Watts, Peluso, & Lewis, 2003) and cognitive reconstructions (Strauch, 2007; Strauch & Strauch,
in press).
Session objective. The objective of this session is to help participants apply their
learning about their strengths and values. The Adlerian, cognitive based activity of creating a
story (cognitive reconstruction) to represent a way of being that is in line with one’s healthy
63
goals is a non-threatening way for participants to consider change and action. The facilitator will
guide participants through this activity in which they write a story about themselves acting as if
they are living their healthy goals and preferred ways of being. I have specifically selected this
activity because it is congruent with the program intention that participants are not being asked
to do or change anything, but just to explore alternatives.
Materials.
•
Blank paper and pen
•
Scrapbook supplies
Check in. (10 minutes). See session two.
Activity. (50 minutes). The facilitator will introduce and describe the activity for this
session (which is based on Strauch, 2007 and Strauch & Strauch, in press) including providing
an example, such as the one noted here. The next step involves the facilitator asking each
participant to make note of two messages or thoughts that may be keeping them stuck in relation
to the eating problem, for example, “I have to be thin to be happy”, or “Purging helps me to deal
with my problems”. With guidance from the facilitator each participant will be asked to think
about an alternate view to these messages that would be more healthful. For example, “I know
now that thinness does not equal happiness and I am experiencing happiness in other ways, like
spending time with my family”, or, “ purging is no longer an option for me, I am learning to
deal with problems directly and this feels safe and comfortable now.” The facilitator will ask
each participant to share their new healthier messages and provide suggestions for change as
appropriate. The facilitator will be listening to ensure that the new messages are in fact
supportive of healthier goals. The counsellor will then ask each participant to write a story that
represents them acting as if these messages were a part of their current or recent experience and
64
to include what it would feel like if this were a part of their current experience. For example, I
remember when I was at my mother’s house and she was talking about going on a diet. At first
all I could think about was purging, but this only lasted for a fleeting moment. I was beginning
to feel upset and found it comfortable to feel my feelings and to address this issue with my mom
directly. I told her that it was upsetting for me to hear her talk about diets and also asked her
not to do this around me anymore. I felt safe and comfortable having this talk with my mom and
letting go of purging. I am learning that being thin does not mean I will be happy and that
authentic happiness can come from so many healthier means. This feels so freeing. Each
participant will read their story aloud to the group and again the facilitator will suggest changes
if there are any concerning or non supportive messages in the stories shared. Lastly, the
facilitator will ask each participant to consider and share the most vivid part of their story and the
feeling that goes along with that vivid image as these will be part of the scrap book activity and
also serve to reinforce the healthy messages of the story. The facilitator will listen to ensure the
images and feelings selected are in line with the healthier goals for each individual participant.
The facilitator will also encourage participants to rehearse or re-read their story as a way to
practice reinforcing these new healthier messages and thoughts.
Scrapbooking. (25 minutes). The facilitator will ask participants to write out their story
on their next scrapbook page and include a depiction of the most vivid part of the story along
with the feeling associated with that.
Closing. (5 minutes). The counsellor will ask each participant to share a word to
describe their experience in the group today.
Session Six: Connecting with Community
65
Session theme. The theme of this session is to continue to work on empowering
participants through the exploration of social justice and social interest opportunities.
Session objective. The objective of this session is to explore the theme of connecting
with one’s community and social justice opportunities. The benefits of connecting with one’s
community include building support and resources, while engaging in social justice or advocacy
activities can be empowering. These concepts are supported by all three theories. During this
session, participants will have the opportunity to explore their own meanings of these terms and
think about how they might engage in such activities.
Materials.
•
Newspapers and journalism magazines
•
Scrapbook supplies
Check in. (10 minutes). See session two.
Introduction. (15 minutes). The facilitator will ask participants to write down the words
social justice, advocacy, and connecting with community. Then the facilitator will ask the
participants to share their own meanings of these terms and the facilitator will also share her own
understanding of these terms and the importance of these factors in relation to empowerment and
feeling supported. Participants will also be asked to share their views about the potential benefits
of engaging with their communities and conducting social justice activities and how this may be
tied to their identity.
Activity. (15 minutes). The counsellor will then ask participants to work in two groups
(of four) and provide each group with three different newspapers or appropriate journalism
magazines (e.g. Macleans Magazine). Each group will be asked to look for examples of social
justice, advocacy, or connecting with community within these media.
66
Discussion. (20 minutes). The counsellor will then ask each group to share their
findings and then to individually share how they may already engage in such activities or how
they could imagine engaging in such activities if they chose to in the future.
Scrapbooking. (25 minutes). The facilitator will ask each participant to create a
scrapbook representation of their own interpretation of the terms social justice, advocacy, and
connecting with their communities including the potential benefits.
Closing. (5 minutes). The counsellor will ask each participant to share a word to
describe their experience in the group today
Session Seven: Tree of Life: Integrating what we’ve Discovered
Session theme. In preparation for ending the group, the theme of this session is to
integrate what the participants may have learned about themselves over the past several weeks
and to reinforce a non-problem dominated view of themselves. This will be done through the
tree of life activity that has been used by narrative therapists (Dickson, 2009; REPSSI, 2007).
Session Objective. In this session, the facilitator will guide the participants through the
steps of creating an illustration of parts of their preferred identity, using a tree metaphor. In
keeping with narrative therapy tenets, this depiction can then be a representation of the many
facets of themselves that are not problem dominated.
Materials.
•
Handout of tree outline (Appendix F), or participants can create their own
•
Scrapbook supplies
Check in. (10 minutes). See session two.
Activity. (55 minutes). The facilitator will share the instructions of the tree of life
activity and metaphor (Appendix G) and then ask the participants to create their own tree of life
67
on their next scrapbook page. While the participants work on their tree of life the counsellor can
encourage conversations about their representations.
Discussion. (15 minutes). The participants will then be asked to go into pairs and share
their tree of life with their partner for approximately 7 or 8 minutes each.
Closing. (10 minutes). Each participant will be asked to share one thing that stood out
for them about their partner’s tree of life.
Session Eight: Ending and Celebrating our (Re) Discovery.
Session theme. Participants will share their scrapbooks as a representation of their nonproblem dominated identities. The intention is that through sharing the story of their scrapbook
this non-problem identity can be reinforced.
Session objective. In this final session participants will have the opportunity to share
their (re) discoveries of their preferred identity through their scrapbooks. In addition to sharing
their scrapbooks, participants will also be guided through a closing ceremony (see activity two)
to end the group.
Materials.
•
Scrapbooks
•
Box of a variety of stones
Check in. (10 minutes). See session two.
Activity one. (50 minutes). The facilitator will ask each participant to take 5-7 minutes to
share their scrapbook with the group.
Activity two. (30 minutes). Ending: Each participant will be asked to consider embracing
the knowledge about themselves that they have gained or reconnected with and to consider
what could be possible for their future if they kept this knowledge close to them. They will
68
then be asked to share a name or image for a possible positive direction or pathway they may
have for their life. In addition to this naming, participants will select a stone (from the box of
stones) that they can take with them to symbolize this pathway.
69
CHAPTER 5
Synthesis and Future Directions
Benefits and Limitations
Both group participants and individuals working in the field of eating disorders can
potentially benefit from this program development. In particular this program can benefit adult
women that feel consumed by their eating problem and are struggling to make change.
Participants who participate in this program will have the opportunity to identify positive aspects
of their identity that they may not have been aware of or connected to prior to the group
program. They will also have the opportunity to focus on and celebrate these positive aspects of
self rather than focusing solely on disordered eating behaviours and dominant (negative)
discourse. In turn, this (re) connecting with a preferred identity may allow for change through
encouraging separation from the problem story as their dominant identity, potentially paving the
way to change or improve their relationship to the problem (White, 2007). In this sense, Lisa
(vignette case) wakes up in the morning after completing the group and instantly thinks about the
meals she will have or not have that day. Rather than automatically succumbing to these
obsessive thoughts, Lisa begins to take more notice of them as the voice of the eating disorder,
thereby objectifying the problem and seeing it as a separate entity. When Lisa has her breakfast
that morning and the eating disorder voice says, “Don’t eat that toast,” she responds aloud, “Be
quiet,” and does eat the toast, further reinforcing the idea of the problem as separate to her.
Through dissemination of this work (once evaluations were collected and demonstrated
some benefits) in peer-reviewed journals or conferences, counsellors working in the field of
eating disorders may have the opportunity to reflect on this integrated approach and apply some
of the ideas within it to individual or group work with women suffering from eating problems.
This program, with its integrated approach and focus on the person rather than the problem, may
70
offer a different way of working with women with eating problems and in particular can be an
additional option for women with whom traditional models of addressing primarily the problem
behaviours and symptoms has not been successful.
Although this 8-week program offers an adjunct to focusing primarily on eating disorder
symptoms, there are circumstances where disordered eating symptoms do need to be addressed
more directly and as a priority, for example, for women at risk of immediate physical harm due
to the disordered eating behaviours. Consequently, this program is not suitable for all women
with eating problems and therefore the appropriate screening precautions should be followed as
described in Chapter 4.
Synthesis
The purpose of this final project was to develop a program that would help women with
eating problems to explore and reconnect with a non-problem dominated sense of self; that is, to
reconnect with a positive or preferred identity. The intention was to do this through an 8-week
psychoeducational group program based on the integration of three theoretical perspectives:
narrative therapy theory, feminist theory, and Adlerian theory. In order to meet this goal there
were two main phases to this project. The first phase included a thorough review of the
literature related to eating disorder prevalence, treatment, and the three theoretical perspectives
on eating disorders and identity. The second phase of this project was the development of the 8week group program, (Re) Discovering who you are: Beyond the Eating Disorder Identity. The
program was successfully developed and is suitable for women with self-defined eating problems
interested in exploring their (non-problem) identities.
Narrative therapy ways of working formed the foundation for this 8-week group program
in that the program is collaborative and honouring of multiple realities and subjective
experiences. In addition to narrative therapy ways of working, literature about feminist and
71
Adlerian theories related to working with eating disorders was consulted to develop this
program, with a particular focus on self-discovery. This collaborative and multi-theoretical
approach can benefit different women in different ways. For example, in a group program the
counsellor may not have the opportunity found in individual work where she or he can
implement the best intervention to suit a client’s unique needs and preferences. Consequently,
offering a program with a variety of interventions can provide multiple possibilities of reaching
different participants in a way that can be individually beneficial.
The counsellor’s role in each session is to encourage participants to consider who they
are as separate from the eating problem. This could involve the counsellor asking particular
questions to help illicit positive aspects of the participants’ identity since this can be difficult
when one is consumed by a problem (White, 2007). For this reason, the first session explores
contextual factors related to the problem in order to encourage some separation from it.
Exploring contextual factors is a tenet that is central to all three theories and begins to situate the
problem as external to the individual. The second session continues to focus on this separation
from the problem through an externalizing conversation which is based in narrative theory
(White, 2005; White, 2007). The third session, also based in narrative theory, begins to explore
alternate possibilities, strengths, and resources through a unique outcome conversation (White,
2005; White, 2007). The fourth session carries on with the theme of focusing on strengths and
also examines personal interests and roles, which is also central to all three theories. The fifth
session, based on Adlerian cognitive ways of working, focuses on healthy goals and thinking and
acting as if these were a part of the participant’s day to day life. Also central to all theories is the
idea of connecting with community and social justice and this is the focus for session six, where
participants explore these ideas as well as consider how they might engage in such activities. In
72
session seven, participants have the opportunity to integrate their learning of self from the
previous weeks (and add to it) through a tree of life activity which is ground in narrative theory.
In each of the first seven sessions participants ended the session by creating a page in
their scrapbook to depict their learning and or experience. The sharing of this scrapbook is the
focus of the last session, followed by a closing ceremony to end the group. Participants keep
their scrapbooks as a reminder of their non-problem dominated identity. By focusing on the
person beyond the problem including what is important to the person, their strengths, interests,
hopes, and values, this group program offers participants the opportunity to consider change and
action through allowing them to see that they are much more than the problem (White, 2007).
Future Directions
The development of this program paves the way for its implementation and evaluation.
A logical next step involves implementing the program with the intended audience and then
evaluating its effects. Once there is an evaluation of the effectiveness of this program, this
information can be shared through the literature or conferences and other counsellors may then
choose to apply some of the concepts in their work both with groups and with individuals.
Further, counsellors and researchers who apply this approach in a one to one therapeutic setting
can also examine the outcomes for clients in individual counselling. Outcomes that are
important to study relate to both the use of this program as one that addresses identity issues as
well as one that offers an integrated approach.
Identity issues in the eating disorder population are also seen in various cultural and
marginalized groups (Moradi & Rottenstein, 2007; Yokoyama, 2007); therefore future directions
may include evaluating the program with various cultural groups or in a multicultural setting.
Lastly the intended groups for this project are small (i.e., approximately 8 women) and these
73
groups will likely be based in community programs related to eating disorders. As such,
applying this program with larger numbers of women and men and in a variety of contexts may
provide information about its usefulness in a more general sense. In closing, this group program
can provide an opportunity to begin to study the relationship of identity in eating disorder
recovery.
74
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Appendix A
Group Program Flyer
(Re)Discovering Who You Are
Beyond the Eating Disorder Identity
(Re) Discovering who you are: Beyond the Eating Disorder Identity is
an 8-week psychoeducational group program for adult women
experiencing an eating problem. Throughout the 8-week
program, participants will have the opportunity to explore the
context of their eating problem as well as parts of their identity
that may be separate from the eating problem. Participants will
explore their strengths, interests, goals, values, hopes, dreams,
and intentions as they reconnect with who they are beyond the
problem. The program also includes creating a scrapbook as a
representation of the participants’ experience.
For more information or to book an appointment to assess the
suitability of this program to your needs please contact:
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Appendix B
Informed Consent
Facilitator Name:
Contact Phone:
Purpose of the Group Program
This psychoeducational group program is for adult women experiencing an eating
problem and focuses on allowing participants the opportunity to reconnect with or discover
aspects of who they are separate from the eating problem. The program includes an integration of
various theoretical perspectives on disordered eating and identity. Participants will be
encouraged to explore the context surrounding eating problems as well as aspects of their
identity, such as, their strengths, interests, goals, values, hopes, dreams, and intentions.
Participants’ explorations will culminate in the development of a scrap book representing their
experience during the 8 weeks.
Participation
This program is available to those that voluntarily register for the program once they’ve
completed the pre-screening assessment with the facilitator. It is anticipated that the group will
consist of approximately 8 adult women who are experiencing self-identified disordered eating
concerns. Participants will be encouraged to attend the 1.5 hour weekly sessions over 8 weeks
however, can withdraw at any time from any part of the program or entirely from the group
program. Participants will be asked to complete an evaluation questionnaire at the end of the last
session which will take approximately 15 minutes to complete. The Questionnaire will be
completed anonymously and the questions will centre on how the participants felt about the
program experience.
Risks of Participating in the Group Program
There is no specific risk to participating in this study. Participants will be provided with
low fee or free counselling contact information in the event that they would like to discuss with
someone any concerns that might arise.
Benefits of Participating in the Study
There may not be any direct benefits to participating in this study or you may experience
some benefits, such as, an increased awareness about personal characteristics.
Confidentiality
The facilitator will maintain confidentiality at all times and all participants will be
encouraged and reminded that discussions in the group are confidential and should not be shared
outside of the group. Confidentiality does not apply when participants express risk of harming
self or others.
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Contact Information and Support
For more information or any questions about this group program please contact the facilitator
with the contact information listed above. If you are in distress at any time during the program
please discuss this with the facilitator. In addition you can access low cost or free counselling
from the following two agencies:
1)
2)
By signing below you acknowledge your understanding and appreciation of the information
presented within this document regarding the 8-week group program.
Participant Name: _____________________________________
Participant Signature: __________________________________
Date: _____________
Facilitator Name: _______________________________________
Facilitator Signature: ____________________________________
Date: _____________
90
Appendix C
Evaluation Questionnaire
1. I would select the following to describe my eating related issues, please check any that
apply:
[ ] I have anorexia
[ ] I have bulimia
[ ] I have disordered eating issues
[ ] I have an eating problem
[ ] I choose none of these labels
[ ] Other, please specify _____________________
2. Overall, attending this group has been helpful to me [ ] Yes
[ ] No
3. This 8-week program provided me with some opportunity to learn more about who I am
as separate from the eating problem:
[ ] Yes
[ ] No
4. Gaining this knowledge about who I am has been a positive experience [ ] Yes
[ ] No
Please share comments about your answer:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
5. Having the scrap book will help me to remember and stay connected to these aspects of
who I am.
[ ] Yes
[ ] No
6. From the following weekly exercises, please select the ones that were most helpful, place
a 1 in the box beside the most helpful activity, a 2 beside the second most helpful and a 3
beside the third most helpful. If none were helpful, please leave this question blank.
[ ] Week 1, Exploring the context of the eating problem
[ ] Week 2, Interviewing the problem about its successes
[ ] Week 3, Interviewing the problem about its failures
[ ] Week 4, Uncovering your interests, roles, and strengths
[ ] Week 5, Writing a story about your preferred ways of being
[ ] Week 6, Exploring social justice and community connection opportunities
[ ] Week 7, Tree of life activity
[ ] Week 8, Sharing your scrapbook
Please comment about any specific aspects of the program that you found helpful:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
91
7. Being with others with similar concerns over these 8 weeks was helpful to me [ ] Yes [ ] No
Comments: ________________________________________________________________
__________________________________________________________________________
8. The facilitator tried to create an environment that was non judgemental and that felt safe to
share my thoughts and feelings: [ ] Yes [ ] No
This contributed to the program being helpful for me [ ] Yes [ ] No
9. If applicable please share what you found most helpful from this 8-week program that you
may not have yet mentioned:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
10. What could be added to improve this program is:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
11. Please share what attracted you to register for this program:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
12. Overall please select how satisfied you were with the program:
[ ] Very Satisfied
[ ] Satisfied
[ ] Dissatisfied
[ ] Very Dissatisfied
13. Additional comments are welcome:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Thank you for your time and participation!!
92
Appendix D
Externalizing Interview Questions
In your pairs take turns interviewing your partner’s eating problem. The interviewee should
imagine that the problem is boastful and forthcoming about how it is successful (White, 2005).
The interviewer should focus on being an interviewer as opposed to a helper (White, 2005). In
other words, it is not the interviewer’s role to fix or cure the problem rather it is to expose the
problem and its identity (White, 2005). The following questions can be used to guide your
interview. Feel free to have fun with some humour.
•
Problem, if you were an image, object, or symbol, what would that be, or what would you
call yourself?
•
(You may insert the name, or image of the problem here and before each of the following
questions, for example, “bulimia” or “dark cloud”…) In what areas of (participant’s
name) life do you have the most influence, for example, at school, work, home, with
friends, around her parents, etc?
•
What do you think it is about these places or people that allow you to be successful?
•
What things do you tell (participant’s name) about herself?
•
How is that you have her believing these things you tell her?
•
Do you have (participant name) doing things that are not good for her? If yes, what are
they?
•
What strategies or tricks do you use that have the most influence on (participant name)?
•
What qualities do you have that take away from (participant’s name) accessing her own
knowledge and skills?
•
Who are your allies?
•
What intentions do you have for (participant’s name) future?
At the end of each of the interviews take a moment to share your thoughts and feelings about this
experience.
93
Appendix E
Unique Outcome Interview Questions
In this interview of your partner’s eating problem you want to expose its failures and
weaknesses. The interviewee should try to openly share the problem’s failures while the
interviewer should focus on exposing these. Despite often feeling dominated by problems, we
have many experiences in our life in which the problem is not as successful. No matter how
small these experiences may seem, they are important to draw attention to. The following
questions can be used to guide this interview. Feel free to have fun with some humour.
•
In what areas of (participant’s name) life do you have less influence; where she has more
influence than you do?
•
Was there ever a time, no matter how small, where (participant’s name) had the upper
hand over you? Please share a story or two about this, including the steps taken by
(participant’s name).
•
What strategies did (participant’s name) use that were effective in getting the upper
hand?
•
What qualities and skills did (participant’s name) use in these circumstances? Is it fair to
say then, that there are times when you are unable to undermine these qualities and skills?
•
What do you think it says about what is important to (participant name) that she has used
these strengths to challenge you? For example, was she protesting or standing up for
something?
•
Who do you think are (participant’s name) allies in challenging you? What might they
tell me about her qualities and skills?
•
If (participant name) kept these allies, qualities, skills, and values close to her, what do
you think might be possible for her future, or what difference could it make for her?
At the end of each of the interviews take a moment to share your thoughts and feelings about this
experience. You may also want to compare this interview to last week’s externalizing interview.
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Appendix F
Tree of Life Outline
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Appendix G
Tree of Life Instructions
Adapted from REPSSI (2007)
Think about your life as a tree and in particular have this tree of life represent the story of
your life that is not problem dominated. It may help to think about your discoveries over the
past six sessions. Feel free to be creative and make your own tree or use the tree outline
provided as a base. The following are the parts of a tree and what they can represent in your
illustration.
•
•
•
•
•
•
ROOTS: where you were born and raised, your family history, ancestry, significance of
your name, etc.
THE GROUND: represents the present, where you live, who you live with, where you go
to school/work if applicable, and some activities that you engage in in daily life. You
may choose to include your favourite place at home.
TRUNK: represents your skills, abilities, qualities, talents, things you’re good at, and so
on. For example, sports, caring for others, your sense of humour, your abilities at school,
etc. It may help to remember what others would describe as your strengths.
BRANCHES: represent the hopes, wishes, dreams, and direction that you want your life
to go in.
LEAVES: represent the people who are important to you. These important figures may
have passed away, or may even include pets and fictional characters.
FRUITS: represent gifts that you have been given; could be material gifts of significance
or also non material gifts, such as, friendship, acts of kindness, support, etc.
As trees do, people also weather difficult storms in their life. It can be helpful to remember
that storms are not always present and that we can have positive experiences when storms
have passed. Think about how you might celebrate these storm-free experiences. This tree is
one way to remember some storm free parts of your life. How else might you hold onto your
dreams and hopes when facing a storm?
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