A Professional Journal of The Renfrew Center Foundation • Summer 2012
CONTRIBUTORS
Glenn Waller, DPhil, FAED
1
Thomas Hildebrandt, Psy.D.
7
A Word from the Editor
C
reating evidence based guidelines for the treatment of eating disorders may have
been the easy part. Dissemination and widespread acceptance of the research
based guidelines seem more elusive. How can clinicians adapt and modify their
protocols to provide effective, and efficient, treatment to an increasingly complex range
of patients with complex clinical symptoms?
Summer 2012 Perspectives addresses the issue of research and treatment manuals.
It also includes updates on group therapy, the unique needs of special populations,
and assessment tools for monitoring treatment progress. We hope these articles are
thought-provoking.
Laura H. Choate, Ed.D., LPC, NCC
10
Charles F. Saladino, Ph.D.
15
Cindy James, Ph.D.
19
Editor: Doug Bunnell, Ph.D.
Assistant Editors: Vanessa Menaged
Alecia Connlain
Doug Bunnell, Ph.D.
editor
COGNITIVE-BEHAVIORAL THERAPY FOR THE EATING DISORDERS:
Some principles to help guide us in delivering
evidence-based practice
Glenn Waller, DPhil, FAED
Vincent Square Eating Disorders Service, Central and North West
London NHS Foundation Trust, and Eating Disorders Section, Institute of
Psychiatry, King’s College London
I
have worked with the eating disorders since 1988. My initial training
was very much in the radical behaviorist tradition, but I soon decided that my
own style was more of a cognitive-behavioral one. At the time, this was almost
rebellious, as my boss was very definite that cognitive work was a passing fad and
not to be pursued – how many people these days can say that choosing to be a
cognitive-behavioral therapist makes them a rebel?
Now, of course, there is a bit of idiocy here. Simply deciding to be a cognitive
behavior therapist does not actually make one a cognitive behavior therapist.
Labels are no substitute for the real thing - a theme that I shall be returning to…
A PROFESSIONAL JOURNAL OF THE RENFREW CENTER FOUNDATION
Over the past quarter of a century1, I
have been through different patterns
of clinical practice and thought. First,
I think I was really more of a behavior
therapist who called his work CBT.
That did not really work very well, so
I took up more of a schema-focused,
cognitive approach. While that was
more challenging intellectually, it did
not really work very well. Throughout,
I would read material about evidencebased CBT for the eating disorders,
and conclude that the patients in the
treatment trials were a weirdly easy
bunch to work with. Certainly, they
could not be as complex as the cases I
worked with every day. However, I tend
to get a nagging voice in my head when
I try to ignore the really, really obvious.
So I tried thinking about whether I
could get better at what I did. I hooked
up with a wonderful supervisor (she
knows who she is), started reading what
the manuals said, felt like a fool, and
started doing more of what the books
said. In short, I stopped hiding behind
the label of CBT and started doing
CBT with my patients. And it worked
much better. Even with the complex
cases. Just like the books said.
To this day, I retain a strong sense of
embarrassment about just how awful
a therapist I was back then. I had the
opportunity to apologize to a former
patient a little while ago. She was very
gracious about it. I have decided that
the best way of avoiding (or reducing)
such embarrassment is to do as good
a job as I can, so that I do not end up
with too much to apologise for. And to
make sure that others do as good a job
as they can.
Who
can I upset first…?
Therein lies an issue - trying to get
others to do the best that they can for
our patient group. I am aware that a
lot of people will not read this article,
seeing it as irrelevant to their practice
Did I really just say that?
I suspect that it will be no bad thing if I am just as
embarrassed in ten more years when I think how
awful I was in 2012. I am not sure that I can avoid
that embarrassment if I want to get better at what
I do, so I had better embrace it.
1
2
PAGE 2
in the eating disorders. I am also pretty
certain that others will actively reject
what I have to say, snorting at the
nonsense that I have come out with3.
Many do and will reject the scientistpractitioner model, seeing it as cramping
their desire for artistic or intellectual
stimulation. I did that myself early in my
career, as I have outlined above. While
I am aware that I might be expected to
name and shame specific therapies here,
to do that would simply be silly. I can
get far more widely irate than that. Such
rejection is not found only among those
who practice more psychodynamic
treatments, but also among all those
who hide behind stances and labels.
While that does encompass a lot (not
all) of psychodynamic approaches, it
also includes those who call themselves
cognitive-behavioral therapists while
doing nothing that looks like CBT. To
sacrifice evidence-based practice for our
own intellectual, artistic and emotional
satisfaction seems unacceptable to me4.
That rejection can be even more
powerful when there is a culture that
is self-perpetuating, and which resists
the implementation of more evidencebased approaches. As a Briton, I am used
to the concept of ‘heroic failure,’ but I
stand in awe of the experience detailed
by Lowe, Bunnell, Neeren, Chernyak &
Greberman (2011), who tried to bring
some elements of CBT into a much
more eclectic therapeutic setting.
My awe is a consequence of knowing
just how typical that pattern of
institutional resistance is – most of us
would be too scared to try what Lowe
and colleagues did5.
In short, a lot of clinicians express the
opinion that using CBT (and evidencebased methods in general) would make
them focus on technique and specific
benefits for the patient, suppressing their
natural inclination to be more of an
artist in delivering therapy that has
ill-defined (or intangible) benefits.
One even hears: “We cannot measure
outcomes, because for our patients to
get better means that they have to get
worse during treatment.” There comes
a point where we have to face the
danger that hiding behind an antiscientific stance is to sacrifice any desire
to help patients to get better.
I think that I prefer the latter, following the Oscar
Wilde dictum of “The only thing worse than being
talked about is not being talked about.”
4
When I go to presentations that are outside my
comfort zone (as I often do – there is always
learning to do), I commonly find myself thinking:
“Go and write a novel, rather than taking it out on
your patients under the guise of effective treatment”, but that might just mean that I need to
take more holidays.
5
3
Delivery of evidence-based
CBT for the eating disorders
All of which brings me to the point
of this paper… just what is needed to
be a good cognitive-behavior therapist?
What are the principles that I would
emphasise, based on my own history
of ineptitude? Though many describe
CBT as a ‘simplistic’ approach, Wilson
(2012) has described CBT as “a
complex therapy, with lots of moving
parts,” which I think is very apt.
Fairburn (Fairburn & Dalle Grave,
2011) has pointed out that CBT is not
one method, but a “family” of methods,
only some of which have any evidence
base6. I am going to focus on evidencebased approaches to CBT for the
eating disorders, which do have a lot of
moving parts and which require a lot of
skill to implement them to best effect.
However, a word of warning. In these
days of CBT-E (Fairburn, 2008), I have
reached the conclusion that there are
many clinicians who practice CBT-H,
where the H stands for ‘homeopathy’ –
take a remedy, water it down, success
it, water it down again, until you get to
a level where there is effectively none
of the active ingredient left, and then
expect it to work7. Clinicians routinely
report ‘watering down’ their use of
evidence-based treatments into part
of a more ‘eclectic’ mix, on the basis of
their clinical judgement (e.g., Tobin,
Banker, Weisberg & Bowers, 2007;
Wallace & von Ranson, 2012). In short,
remove the hard parts from CBT and
it gets easier to do but less effective. We
can do better than placebo effects, but
Brave people, and I hope they had a holiday
after that piece of work, too.
6
I would take that a little further – the family
really do not get on, and communicate only
intermittently, with a degree of misunderstanding
and occasional venom.
7
Yes, I am being short on detail, but so are most
accounts of how homeopathy is meant to work.
Besides, if I gave more detail, that might mean
that it stopped working.
PERSPECTIVES • SUMMER 2012
PAGE 3
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A PROFESSIONAL JOURNAL OF THE RENFREW CENTER FOUNDATION
evidence-based CBT is hard work for
clinician and patient alike.
Just as problematic, there are clinicians
who start off using evidence-based CBT
(and those who use other therapies),
but who drift off into doing something
that is not evidence-based CBT (Waller,
2009). Sometimes that drift appears to
be so inexplicable and uncharted that
it reminds me of the Marie Celeste –
found in the middle of the ocean, with
no explanation for how it got there, no
crew, and no idea of what had happened
to them.
Principles underlying evidence-based CBT for
the
eating disorders
So, here are some principles that I
have found to be useful – how to take
the basic practice of CBT for the eating
disorders and make it work for the
patient’s benefit. Most of these principles
have been developed through a long
process of learning with my patients,
my peers, my supervisors, and my
supervisees, to all of whom I owe both
lots of gratitude (and some heartfelt
apologies). Most of these principles are
based on my work with adult outpatients, and I leave it to those who
work with younger cases and in more
intensive settings to determine how to
translate them to those groups8.
Principle 1:
Attend to the evidence base
The evidence base has gaps, but that
is no reason for not knowing about it
or using it. There are plentiful reviews,
which reach broadly similar conclusions (e.g., Bulik et al., 2007; National
Institute for Clinical Excellence, 2004;
Shapiro et al., 2007), and there is good
evidence that this approach works outside research settings (Ghaderi, 2006).
Just because something does not work
for everyone (and CBT does not work
for everyone), we should not ignore
CBT in favour of other therapies
where trying CBT would be the most
appropriate option. The evidence for
treatment matching in adult cases is
pretty negligible. Similarly, we should
not over-simplify, and assume that we
can stop enquiring and developing
where there is a treatment that works
Note – I did not say that they should ‘ignore’ the
evidence base.
8
for some or even most patients. An
understanding of the complexities of
the eating disorders explains why we
need to be able to adapt the therapy to
the individual case (Strober & Johnson,
2012).
Principle 2:
Read and use the manuals
There are lots of manuals to guide CBT
for the eating disorders (e.g., Fairburn,
2008; Gowers & Green, 2009; Waller,
Cordery, Corstorphine, Hinrichsen,
Lawson, Mountford & Russell, 2007).
Clinicians who use those manuals are
more likely to deliver the relevant
elements of CBT (Waller, Stringer &
Meyer, 2012). This sounds obvious.
However, a scarily small number of
clinicians use manuals when working
with the eating disorders, whatever the
therapy that is being delivered
(e.g., Tobin et al., 2007; Wallace &
von Ranson, in press; Waller, Stringer
& Meyer, 2012). Clinical judgement
should be combined with the use of
manuals, rather than being used to
supplant them.
Principle 3: Do the basics
At heart, CBT is more of a ‘doing
therapy’ than a ‘talking therapy.’ The
effective elements include helping the
patient to eat appropriately, monitoring
intake, weighing the patient, using
exposure, behavioral experiments, etc.
Yet only a minority of CBT clinicians
report using these methods on a regular
basis (Waller, Stringer & Meyer, 2012).
So is everyone focusing on cognitive
restructuring? Again, this seems to be
a minority activity among clinicians
(Waller, Stringer & Meyer, 2012). I often
find myself facing the question of what
is it that goes on under the label of
‘CBT.’ Then I assess a patient who has
been treated using ‘CBT’ several times
before, and I ask about what happened
in the therapy, and I am none the wiser.
Being blunt, it seems to me that the best
way of avoiding embarrassment about
what we do is to give the patient the
most effective therapy possible, so that
they never need to go on to a further
therapist and demonstrate that they had
an incomprehensible treatment before.
Do the basics.
Principle 4: Understand
PAGE 4
the link
between the therapeutic alliance
and treatment outcome
While there is a lot of opinion about
the importance of the therapeutic
alliance in driving positive outcomes,
the evidence is relatively weak, especially
where the treatment is a relatively
structured one (Crits-Christoph,
Baranackie, Kurcias, Beck, Carroll, Perry,
Luborsky, McLellan, Woody, Thompson,
Gallagher & Zitrin, 1991). Indeed, in
some areas of psychopathology, the
evidence is that the link is the other
way round. The best predictor of a
good therapeutic alliance is a positive
change in behaviors and symptoms as
treatment progresses (Webb, DeRubeis,
Amsterdam, Shelton & Hollon, 2011).
Whatever the direction of causality,
patients undertaking evidence-based
CBT for the eating disorders report a
good working alliance with their
clinicians early in treatment (Waller,
Evans & Stringer, 2012). Always bear
in mind the notion of the therapeutic
relationship in CBT requiring a
“judicious blend of empathy and
firmness” (Wilson, Fairburn & Agras,
1997).
Principle 5: Tolerate uncertainty
I have often reflected that the best
CBT clinicians are those who are
not afraid to try change, wait for long
enough to find if it works, and then
plan the next step. In other words,
they tolerate uncertainty. If you need to
know the answer now, then being
a cognitive-behavioral therapist is
probably not a good career choice.
After all, you have to be calm while
the patient does all the worrying – and
CBT will not work unless the patient
experiences anxiety about change
(e.g., eating more, facing body image).
Another term for this is “Be boring.”
Embrace your boring side, because the
patient needs you not to be anxious.
When the patient’s weight changes
between meetings, stick to your guns
and do not get excited, because the
patient needs to know that you meant it
when you said “This is going to take
several weeks…” Remember that anxious
CBT clinicians are more likely to be
those who avoid using core CBT techniques (Waller, Stringer & Meyer, 2012).
PERSPECTIVES • SUMMER 2012
Principle 6: Treat
motivational
enhancement as an ongoing process
There is (at best) minimal evidence
that pre-treatment motivational work is
effective in enhancing therapy outcomes
(Waller, 2012), and yet over half of CBT
clinicians report using this approach
(Waller, Stringer & Meyer, 2012).
Motivational work can be really
valuable, but not when one treats it as
a precursor to therapy. CBT clinicians
need to avoid being part of the problem,
and should not delay starting therapy
until the motivational work has woven
its (presumed) magic. Early behavioral
change (and positive feedback from
the clinician and the world) is much
more likely to encourage further
improvement (see below) and a positive
therapeutic alliance (see above).
Principle 7: Review progress
(or the lack of it)
CBT is not a ballistic approach to
therapy. We cannot simply start it, and
then assume that it will continue on its
planned course. We need to respond to
positive change by being reinforcing
(many patients have never before had a
successful dose of therapy, and need to
learn that success is down to their own
efforts). We need to respond to
stuckness by being clear about it, and
helping the patient to identify ways
around it. There is evidence that early
behavioral change is a key determinant
of later progress in different therapies
for the eating disorders (e.g., Agras,
Crow, Halmi, Mitchell, Wilson &
Kraemer, 2000; Doyle, Le Grange, Loeb,
Doyle & Crosby, 2010; Wilson, Loeb,
Walsh, Labouvie, Petkova, Liu &
Waternaux, 1999), so be firm about the
need to change from very early on –
give the patient a choice about having
the best chance to get well. It is possible
that such a review will result in deciding
to change therapeutic direction – that is
fine, as long as the patient had the best
chance of recovery in the first place. In
short, if you have been delivering CBTH, then all that says is ‘try an evidencebased form of CBT.’
Principle 8: Get out of the rut
Even if practiced in the most
appropriate way possible, CBT for the
eating disorders is not perfect by any
means. So we should always be aiming
to improve what we deliver by keeping
up to date. However, we also need to
get ahead of the game. I commonly
find that attending general CBT
conferences, reading more widely in the
field of CBT, and plundering ideas from
colleagues who know nothing of the
eating disorders means that I find new
ideas (well, new to the eating disorders,
anyway), which can be invaluable in
working with my patient group.
CONCLUSIONS
Earlier, I mentioned the anticipated
reactions of different people on reading
this article. I missed out one very
important group. Some people did not
need to read this article - it will have
told them nothing new and will not
have added one little bit to their practice, because they are already doing all
this. Ironically, those are the people who
are most likely to have read this far, in
case there was something new that they
needed to learn. Sorry to disappoint you,
but delighted to meet you. I just wish
there were more of you.
There are many wonderful clinicians
in this field.There are some great
treatment approaches – not just CBT.
However, most clinicians do not use
them, making all the mistakes that I
made myself back in those first few
years.Within CBT, there is an evidencepractice gap – many CBT clinicians miss
the point of what they need to do and
why, resulting in scary failures to deliver
empirically-supported treatments.The
manuals are easy to obtain and can
guide us towards better practice (Waller,
Stringer & Meyer, 2012), but are not as
widely used as they should be (Tobin
et al., 2007).This pattern of manual use
is not random (Wallace & Von Ranson,
in press), meaning that there are clear
opportunities for improving uptake.
However, simply having the tools is not
enough. We need to be able to reflect
on why we do what we do when we
do it. The aim of this review has been
to address that need in just one area
of treatment for the eating disorders –
identifying therapeutic principles that
can help us to keep CBT on target,
rather than drifting as cognitivebehavioral therapists. I hope that there
have also been ideas that will prove
useful to those using other therapies
PAGE 5
as well.What I would most like to see
would be for all clinicians to have a set
of principles underlying their use of the
best possible practice for their patients,
regardless of the therapy concerned.
However, that requires us all to be
focused on being scientist-practitioners
rather than artists.
Speaking of artists, there is a line at
the end of the Beatles’ ‘Let It Be’ film
where one of the Moptops concludes
by saying “I’d like to say thank you on
behalf of the group and ourselves and I
hope we’ve passed the audition,” I have
this horrible idea that I might get to the
end of my career and feel that I have
failed the audition, but I hope the many
clinicians who are better than me will be
pushing the envelope of evidence-based
practice, and that the principles outlined
here will help.
REFERENCES
Agras,W. S., Crow, S. J., Halmi, K. A.,
Mitchell, J. E.,Wilson, G.T., &
Kraemer, H. C. (2000). Outcome
predictors for the cognitive behavior
treatment of bulimia nervosa: Data from
a multisite study. American Journal of
Psychiatry, 157, 1302-1308.
Bulik, C. M., Berkman, N. D., Brownley,
K. A., Sedway, J. A., & Lohr, K. N. (2007):
Anorexia nervosa treatment: A systematic review of randomised controlled trials.
International Joural of Eating Disorders, 40,
310-320.
Crits-Christoph, P., Baranackie, K.,
Kurcias, J. S., Beck, A.T., Carroll, K.,
Perry, K., Luborsky, L., McLellan, A.T.,
Woody, G. E.,Thompson, L., Gallagher,
D., & Zitrin, C. (1991). Meta-analysis
of therapist effects in psychotherapy
outcome studies. Psychotherapy Research, 1,
81-91.
Doyle, P. M., Le Grange, D., Loeb, K.,
Doyle, A. C., & Crosby, R. D. (2010).
Early response to family-based treatment
for adolescent anorexia nervosa.
International Journal of Eating Disorders, 43,
659-662.
Fairburn, C. G. (2008). Cognitive
behavior therapy and eating disorders.
New York, NY: Guilford
A PROFESSIONAL JOURNAL OF THE RENFREW CENTER FOUNDATION
Fairburn, C. G., & Dalle Grave, R.
(2011). Enhanced CBT (CBT-E) for
anorexia nervosa: A three site study.
Paper presented at the International
Conference of Eating Disorders. Miami,
FL, April.
Ghaderi, A. (2006). Does individualization matter? A randomized trial of standardized (focused) versus individualized
(broad) cognitive behavior therapy for
bulimia nervosa. Behaviour Research and
Therapy, 44, 273-288.
Gowers, S. G. & Green, L. (2009). Eating
disorders: Cognitive behaviour therapy with
children and younger people. London, UK:
Routledge.
Lowe, M. R., Bunnell, D.W., Neeren,
A. M., Chernyak,Y., & Greberman, L.
(2011). Evaluating the real-world
effectiveness of cognitive-behavior
therapy efficacy research on eating
disorders: a case study from a
community-based clinical setting.
International Journal of Eating Disorders,
44, 9-18.
National Institute for Clinical
Excellence (2004). Eating disorders:
Core interventions in the treatment
and management of anorexia nervosa,
bulimia nervosa and related eating
disorders. Clinical guideline 9. London:
National Collaborating Centre for
Mental Health.
Shapiro, J. R., Berkman, N. D., Brownley,
K. A., Sedway, J. A., Lohr, K. N., & Bulik,
C. M. (2007). Bulimia nervosa treatment:
a systematic review of randomized
controlled trials. International Journal of
Eating Disorders, 40, 321-336.
Strober, M., & Johnson, C. (2012).The
need for complex ideas in anorexia
nervosa:Why biology, environment, and
psyche all matter, why therapists make
mistakes, and why clinical benchmarks
are needed for managing weight
correction. International Journal of Eating
Disorders, 45, 155-178.
Tobin, D. L., Banker, J. D.,Weisberg, L.,
& Bowers,W. (2007). I know what you
did last summer (and it was not CBT):
A factor analytic model of international
psychotherapeutic practice in the eating
disorders. International Journal of Eating
Disorders, 40, 754-757.
Wallace, L. M., & von Ranson, K. M.
(2012). Perceptions and use of
empirically-supported psychotherapies
among eating disorder professionals.
Behaviour Research and Therapy, 50,
215-222.
Wallace, L. M., & von Ranson, K. M.
(in press).Treatment manuals: Use in the
treatment of bulimia nervosa. Behaviour
Research and Therapy.
Waller, G. (2009). Evidence-based
treatment and therapist drift. Behaviour
Research and Therapy, 47, 119-127.
Waller, G. (2012).The myths of
motivation:Time for a fresh look at
some received wisdom in the eating
disorders? International Journal of Eating
Disorders, 45, 1-16.
Waller, G., Cordery, H., Corstorphine,
E., Hinrichsen, H., Lawson, R.,
Mountford,V., & Russell, K. (2007).
Cognitive-behavioral therapy for the
eating disorders: A comprehensive
treatment guide. Cambridge, UK:
Cambridge University Press.
Waller, G., Evans, J., & Stringer, H.
(2012).The therapeutic alliance in the
early part of cognitive-behavioral
therapy for the eating disorders.
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45, 63-69.
Waller, G., Stringer, H, & Meyer, C.
(2012).What cognitive-behavioral
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when delivering cognitive-behavioral
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171-175.
PAGE 6
Webb, C. A., DeRubeis, R. J.,
Amsterdam, J. D., Shelton, R. C., &
Hollon, S. D. (2011).Two aspects of the
therapeutic alliance: Differential relations
with depressive symptom change. Journal
of Consulting and Clinical Psychology, 79,
279-283.
Wilson, G.T. (2012). Dissemination
and implementation of evidence-based
treatments for eating disorders. Keynote
presentation at the Eating Disorders
International Conference, London, April.
Wilson, G.T., Fairburn, C. G., & Agras,
W. S. (1997). Cognitive behavioral
therapy for bulimia nervosa. In D. M.
Garner, & P. E. Garfinkel (Eds.),
Handbook of treatment for eating disorders
(pp. 67–93). New York: Guilford.
Wilson, G.T., Loeb, K. L.,Walsh, B.T.,
Labouvie, E., Petkova, E., Liu, X., &
Waternaux, C. (1999). Psychological
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of change. Journal of Consulting and
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Glenn Waller, DPhil,
FAED is a Consultant
Clinical Psychologist
with Central and North
West London NHS
Foundation Trust. He is
visiting Professor of
Psychology at the Institute
of Psychiatry, King’s College London. He
has published widely on the subject of the
eating disorders, including over 200 peerreviewed papers, and being lead author on a
book on CBT for the eating disorders. He has
presented clinician workshops at a range of
national and international conferences.
PERSPECTIVES • SUMMER 2012
PAGE 7
Athletes and Eating Disorders
Thomas Hildebrandt Psy.D.
I
n athletics and many forms of competition, “winning” is the dominant culture where norms supported by
every participant, from competitor to fan, can share in the same ultimate goal—to achieve victory.Whether that
competitor is a runner, swimmer, football player, or bodybuilder, it is common to adopt a culture of winning. For
individuals competing in these sports, attributes like coordination, speed, and focus are essential to being the best, but
in some cases the sport relies heavily upon an individual’s strength and physique. Sports such as swimming, diving, and
wrestling, place a large emphasis on maintaining a specific body type - one that may not be easily attainable through
“normal” patterns of eating and exercise. As a result, certain athletes have felt pressure to “make weight” or “slim down”
in order to improve their performance at their sport of choice and ultimately link body type with the winning culture.
In instances like this, unfortunately, many
athletes will adopt disordered patterns of
eating and rigorous exercise patterns,
putting them in great danger of
developing an eating disorder.
Some research studies have suggested
a higher prevalence of eating disorders
in athletes versus the general population
(Greenleaf, Petrie, Carter & Reel, 2009;
Sundgot-Borgen & Torstveit, 2004).
Many of these individuals who are in
fact suffering from eating disorders are
viewed as determined, disciplined, and
dedicated to their sport training, but
these may be just masking a pattern
of pathological behaviors. Population
based studies of eating disorders suggest
that less than 1percent of women meet
criteria for anorexia nervosa. One to 2
percent meet criteria for bulimia nervosa
and between 3-5 percent meet criteria
for eating disorder not otherwise
specified (EDNOS; meaning that an
individual meets most, but not all of the
criteria for anorexia or bulimia).The
same study found that the prevalence
for an eating disorder in men was
between .5 and 2 percent (Hudson,
Hiripi, Pope & Kessler, 2007).
In athletes, Sundgot-Borgen and
Torstveit (2004) found 13.5 percent of
athletes had an eating disorder diagnosis
compared to 4.6 percent in controls.
Although the causes of eating disorders are complex, inferring a direct link
between athletics and the etiology of an
eating disorder would be impossible.
The athletic environment provides a
unique context for the expression of
eating pathology. Although thin ideal
internalization is a robust risk factor for
eating disorder pathology (Stice & Shaw,
2002), the athletic context can alter this
ideal to reflect a lean but muscular
physique. Thus, the sociocultural
pressures embedded in many athletic
contexts is likely to reflect the idealized
body type for that individual sport
and may actually insulate against the
broader sociocultural norms of thinness
and beauty.
Peer pressures in athletic environments
are also unique because violation of
group norms can carry the added
weight of team, coach, or school
achievement. When teams or individuals
adopt norms that involve extreme dieting,
weight control, or fitness standards,
vulnerable individuals will find it harder
to choose to express these norms in a
healthy way. Some of the psychological
vulnerabilities to eating disorders may
also conform to these peer supported
cultural norms. Athletes with traits such
as perfectionism, goal directedness, and
willingness to tolerate pain, or withhold
reward, to achieve victory are often
idealized in athletic environments.
These same traits affect many with
eating disorder pathology.
In athletes, the body type requirements
impose certain restrictions that can affect
the person’s eating behavior. Research
has found that individuals participating
in leanness-dependent and weightdependent sports (i.e., gymnastics or
wrestling) have a higher rate of eating
disorder pathology compared to
those who participate in sports that
do not impose weight restrictions
(Sundgot-Borgen & Torstveit, 2004).
Further, this drive for thinness is
expressed very differently in women
and men. For women, the drive for
thinness derives from both societal
pressure as well as that for their sport.
Female athletes tend to report more
eating and body shape concerns above
and beyond the degree to which it
would affect sport or athletic performance.
This drive is behaviorally manifested
in greater levels of dietary restraint and
increased intensity and frequency of
exercise. For men, this same drive is
more sport and performance specific,
but also has deep roots in societal pressure
to comply with masculine ideals for
physique and strength (Hildebrandt,
Shiovitz, Alfano, & Greif, 2008).
Men generally show fewer problematic
eating patterns compared to women,
but are significantly more likely to
use substances to alter their body
(Hildebrandt, Langenbucher, Lai, Loeb,
& Hollander, 2011). These substances
range from over-the-counter substances
such as protein supplements to illegal
substances such as prohormones, growth
hormone, and anabolic steroids.
Consistent with this expression of shape
and weight control, men are more likely
to express a drive for muscularity or
bulk, or in many cases an extreme ideal
of leanness and muscularity.
Female Athletes
and Eating Disorders
The Female Athlete Triad is a term
used to describe the triangular effect
eating disorders have on the female
body. The phenomenon is comprised
of a series of repercussions from eating
disordered behaviors such as low energy
due to lack of food consumption,
amenorrhea or the loss of menstruation,
and low bone density known as
osteoporosis (Nattiv et al., 2007).
Other chronic and serious effects of
eating disorder behaviors (i.e., restrictive
A PROFESSIONAL JOURNAL OF THE RENFREW CENTER FOUNDATION
dieting and/or purging) include nutrient
deficiencies, fatigue, frequent infection
and illness, iron deficiency, frequent
injuries, dehydration, and electrolyte
abnormalities. Although seen across
all athletes with eating disorders, these
effects are most often observed among
females participating in sports that
emphasize leanness. In the case of female
athletes, such complications can result in
even more hazardous medical outcomes,
as the intense exercise schedule that they
impose upon themselves leaves them
at increased risk for many poor health
outcomes (Deimel & Dunlap, 2012).
As a consequence of their poor
nutritional status and overtraining, these
female athletes may, in fact, be worsening
their athletic performance despite any
temporary improvement that occurs
from weight loss or fitness changes.
The initial improvement often leads to
an overinvestment in the association
between shape or weight control and
athletic performance which may be
hard to break if the athlete has achieved
any success. Perhaps unique to eating
disordered athletes, injuries and poor
performance outcomes that result from
continued disturbances in eating and
weight may not be enough to motivate
them to begin healthy eating.
Male Athletes and
Eating Disorders
Female athletes are not the only ones
to feel the athletic subculture’s pressure
to look a certain way to achieve success
at sports or athletic trainings. Men also
feel that pressure, though sometimes
in a very different way. Just as there is
a societal “thin ideal” for women, the
“muscular ideal” for men has become
more apparent (Cafri et al., 2005).
In athletic environments, men typically
feel the need to attain the lean muscular
physique. There is a different ideal in
other areas of athletics that can be
conflated with the “alpha male” persona
or masculine ideal. This persona
embodies an aggressive, fearless, and
ruthless ideal that drives the athletic
culture of winning. These are the same
character traits that may predispose men
to use appearance or performance
enhancing drugs (APEDs) (Irving,
Wall, Neumark-Sztainer, & Story, 2002)
and which are highly valued in male
athletic environments. The medical
risks for APED use are in many ways
more diverse than those associated with
disordered eating and depend largely
on the specific substances. Perhaps the
most acutely dangerous of these effects
originate from the cardiac stress caused
by the mixture of heavy weight training,
potent stimulants, and anabolic agents
that can increase heart size or alter
functional markers of cardiac
performance (Langenbucher,
Hildebrandt, & Carr, 2008).
Gateway Theory To APED Use
The theory known as the ‘gateway
hypothesis’ describes a paradigm of
drug use which positions the gateway
substance as an initial step in the
developmental process of more severe
drug use. Drug use is started during
adolescence and typically progresses
from legal substances such as alcohol
or cigarettes use to illegal drugs such
as marijuana or cocaine.The gateway
theory suggest that this initial use (a)
often co-occurs with the use of a more
dangerous substance; (b) leads to an
increased likelihood of future drugs;
and, (c) through a range of social or
biological mechanisms causes, some
individuals to use the more severe drug.
Consistent with this theory, the use of
serious illicit drugs such as cocaine or
heroin rarely occurs without prior
experimentation with other illicit and
licit substances.
APED use by athletes often has
this same progression.Traditionally,
many individuals turn to nutritional
supplements to increase their capabilities
when beginning their athletic career.
As a result, it can be hypothesized that
nutritional supplements may act as a
gateway to anabolic steroid use or other
illicit APEDs. There is some evidence
to support this progression among
college age men and women
(Hildebrandt, Harty, & Langenbucher,
In press) and implicates a social
mechanism whereby supplement use
offers social access to individuals who
use illicit APEDs. Vulnerable athletes
are drawn to supplements as a way to
gain a competitive edge and can be
seduced by extreme promises of the
supplement advertisements or
cultural lore, much in the same way
that women are seduced by the promises of dietary control. Use of these
fitness or nutritional supplements can
provide the initial “gateway” to the
PAGE 8
experience of using more potentate
substances (i.e. steroids) to alter
appearance. Although social exposure
provides one type of contaminant, legal
supplements may also provide direct
exposure to a range of illicit APEDs.
Because supplements are unregulated
by the Federal Food and Drug
Administration (FDA), the manufacturing practices can become vulnerable to
contaminants including illicit APEDs.
Complicating the identification of
APED use among athletes is the
diversity of body image ideals adopted
by athletic subcultures. For instance, the
idealized marathon runner will have a
very different body than that of the
idealized powerlifter. This variation in
bodily ideal is well documented among
men (Hildebrandt, Alfano, &
Langenbucher, 2010), but brings with it
a corresponding diversity of substances
needed to achieve these ideals. APEDs
can include substances used to alter one’s
outward appearance or improve physical
performance. The polypharmacy that
APED users engage in often involves
substances from multiple drug classes
including supplements, thyroid hormones,
beta-agonists, synthetic androgens,
aromatase inhibitors, pain killers, and
others.With an ever evolving drug
marketplace, detection methods are
unlikely to ever be fully successful.
Furthermore, the knowledge and
sophistication of the APED-using
community allows interested users to
gather information quickly and
effectively. Many existing materials such
as ‘steroid bibles’ and online forums or
web-pages provide interested users with
information about what substances to
use when and how to manage side
effects. The general theme is that these
substances are safe and effective, but
also must be used appropriately to yield
necessary results. It is within many of
these communities that the social norms
around APEDs originate and in which
their use by athletes is adopted and
reinforced.
APED Warning Signs
and Testing
Many athletes take steroids via
injections, transdermal patches, or orally.
This, in combination with extensive
exercise and weight lifting, enables
athletes to develop muscle tissue at a
rapid pace, far beyond natural means.
PERSPECTIVES • SUMMER 2012
The primary obvious sign of steroid use
among athletes involves a drastic increase
in overall muscle bulk or bloating.
Less obvious psychological signs
include a tendency towards increased
aggression, impulsivity, irritability,
restlessness, trouble breathing, and
feelings of grandiosity or imperviousness
(to a level approaching mania).
Individuals using steroids may also
experience more physical symptoms
such as an elevated sex drive and
increased acne in the back or chest area.
As a result, a paradox appears within
the athletic community as the reasons
that bring athletes to use steroids (i.e.,
health benefits, appearance, increased
athletic ability), also lead to potential
health risks, particularly with long-term
or problematic use.These prolonged
patterns of steroid use in conjunction
with disordered patterns of eating
exacerbate potential negative side-effects
including exaggerated hormonal
imbalances, heart arrhythmias, and liver
problems. However, these and many of
the side effects associated with steroid
use have suffered from a poor clinical
literature base and absence of well
designed research. Nevertheless, these
concerns seem to be secondary to the
athletes who seek a quick fix for
their perceived athletic or muscular
insufficiencies.
Among sanctioned organized sports
and athletics, most forms of illicit APED
use is prohibited, and drug testing for
APEDs is an expensive and complex
undertaking.The most common
procedures to test for whether or not
an individual may be using APEDs are
through a blood draw, or through hair
and urine collection. The most basic
analyses include testing for free
testosterone or and testosterone/
epitestosterone (T/E) ratio. More
sophisticated methods are available for
identifying specific substances, but there
is no test that is impervious to errors.
The side effect, however, of the increased
focus on testing is the further effort to
conceal and deny APED use which can
result in APED users not seeking help
when his or her use becomes problematic.
This avoidance of help seeking is likely
to be even greater among APED users
with other significant eating pathology
because of additional stigma or
ambivalence about the disease.
PAGE 9
Eating Disorder Prevention
and Intervention Among
Athletes
The prevention and intervention
programs for athletes are best delivered
through a system that supports early
detection, recovery, and careful
reintegration of the eating disordered
or APED-using athlete back into his or
her athletic career. Recommendations
typically include the use of a sports
management team comprised of health
professionals who are not governed by
the athletic system, and who are able
to make decisions about psychiatric or
physical health in a way that serves the
individual over the sport. Unfortunately,
these types of systems are rare and/or
costly, leading to reliance on existing
professionals such as athletic trainers or
sports medicine doctors, to identify and
often treat affected individuals. In high
school athletes, the Athletes Training &
Learning to Avoid Steroids (ATLAS)
and Athletes Targeting Healthy Exercise
& Nutrition Alternatives (ATHENA)
award-winning programs target risk
factors for eating disorders and APED
use through peer engagement and have
proven effective in large scale research
trials (Goldberg et al., 1996). The same
types of programs are still absent for
collegiate athletes and no empirically
supported programs exist for
community based athletics.
Future Thoughts
Considerations
and
Although there is better recognition
of the special needs of eating disordered
athletes now than there may have
been 10 years ago, there are few, if any,
interventions available for APED-users.
Although many of the same clinical
features are present in both APED users
and eating disordered athletes, we have
failed to develop specific interventions
for this population. The masculine ideal
that pervades many athletic contexts
is often incompatible with existing
treatment models that tries to prevent
them from maintaining or reaching this
idealized goal. For instance, the masculine norms suggest that men are not to
receive help and more masculine men
are less likely to need help. Furthermore,
the idealized masculine male does not
feel weak or need to cheat to achieve his
goals.These masculine norms are quite
inconsistent with the model of oneon-one therapy centered on emotional
expression. However, this forces health
professionals with appropriate
knowledge or skills to find creative ways
to access this population. One potential
method is through the use of mental
skills or performance based coaching.
Sport psychologists, nutritionists, or
similar professionals are uniquely
positioned to access this population
because of the ability to be engaged as
just another coach. Unless athletic
cultures change, it is likely that this
type of position will be essential to the
sporting environment to help individuals
suffering from eating disorders or
APED use.
In summary, eating disorder specialists
are well positioned to aid in the
identification and treatment of athletes
with eating disorders. The role of the
specialist, however, may involve
participating in screening assessments
within an athletic department or as
a consultant working with a team or
athlete for reasons quite different than
eating pathology. Furthermore, the
trained specialist should be aware of the
sporting culture that may share many
extreme norms and behaviors often
found among those with an eating
disorder. For these reasons, treatment
is often better delivered in treatment
contexts outside the influence of athletic
administration. The unique problem of
APED use suffers from the culture of
drug testing and being further
embedded in masculine ideals that
are inconsistent with seeking help for
mental or physical health problems.
Professionals are encouraged to engage
these potential patients in creative ways
such as through the role of performance
coach or mental skills coach. This type
of role may allow for greater access to
this vulnerable population.
REFERENCES
Cafri, G.,Thompson, J. K., Ricciardelli,
L., McCabe, M., Smolak, L., & Yesalis,
C. (2005). Pursuit of the muscular ideal:
Physical and psychological consequences
and putative risk factors. Clinical
Psychology Review, 25(2), 215-239.
Deimel, J. F., & Dunlap, B. J. (2012).
The female athlete triad. Clinics in Sports
Medicine, 31(2),247-254.
A PROFESSIONAL JOURNAL OF THE RENFREW CENTER FOUNDATION
Greenleaf, C., & Petrie, T. A., Carter,
J., & Reel, J.J. (2009). Female collegiate
athletes: prevalence of eating disorders
and disordered eating behaviors. Journal
of American College Health, 57(5), 489495.
Goldberg, L., Elliot, D., Clarke, G. N.,
MacKinnon, D.P., Moe, E., Zoref, L….
Lapin, A. (1996). Effects of a multidimensional anabolic steroid prevention
intervention.The Adolescents Training
and Learning to Avoid Steroids (ATLAS)
Program. Journal of the American Medical
Association, 276, 1555-1562.
Hildebrandt,T., Alfano, L., & Langenbucher, J. (2010). Body image disturbance
among 1000 appearance and performance enhancing drug users. Journal of
Psychatric Research, 44, 841-846.
Hildebrandt,T., Harty ,S., & Langenbucher, J. (in press). Fitness supplements as
a gateway substance for anabolic androgenic steroid use. Psychology of Addictive
Behaviors.
Hildebrandt,T., Langenbucher, J.W,
Lai J. K., Loeb, K. L., Hollander E.
Development and validation of the
appearance and performance
enhancing drug use schedule. Addict.
Behav. Oct 2011;36(10):949-958.
Hildebrandt T, Shiovitz R, Alfano L,
Greif R. Defining body deception and
its role in peer based social comparison
theories of body dissatisfaction. Body
Image. Sep 2008;5(3):299-306.
Hudson, J. I., Hiripi, E., Pope, H. G., &
Kessler, R. C. (2007).The prevalence and
correlates of eating disorders in the National Comorbidity Survey Replication.
Biological Psychiatry, 61, 348-358.
Irving, L. M.,Wall ,M., NeumarkSztainer, D., & Story, M. (2002). Steroid
use among adolescents: findings from
Project EAT. Journal of Adolescent Health,
30, 243-252.
Langenbucher, J., Hildebrandt,T., &
Carr, S. (Eds.). (2008). Medical
consequences of performance enhancing
drug use, 2nd ed. New York:
Hawthorne Medical Press.
Nattiv, A., Loucks, A. B., Manore, M. M.,
Sanborn, C. F., Sundgot-Borgen, J.,
Warren, M. P., & American College of
Sports, M. (2007). American College
of Sports Medicine position stand.The
female athlete triad. Medicine, Science,
Sports & Exercise, 39(10), 1867-1882.
Stice, E., & Shaw, H. E. (2002). Role
of body dissatisfaction in the onset and
maintenance of eating pathology:
PAGE 10
A synthesis of research findings. Journal of
Psychosomatic Research, 53, 985-993.
Sundgot-Borgen J., & Torstveit, M. K.
(2004). Prevalence of eating disorders in
elite athletes is higher than in the general population. Clinical Journal of Sport
Medicine, 14, 25-32.
Thomas Hildebrandt
Psy.D. received his
doctorate from Rutgers
University and completed
his Post-Doctoral
Fellowship in Eating and
Weight Disorders at the
Mount Sinai School of
Medicine before becoming Director of the
Eating and Weight Disorders Program.
He founded the Program for Appearance
and Performance Enhancing Drug (APED)
research in 2007 and is actively involved in
clinical practice, research, and teaching.
His research interests span three major areas:
(1) development and evaluation of clinical
interventions for adolescents and adults with
eating and weight disorders or adults with
alcohol use disorders; (2) psychiatric and
physical consequences of APED use or
anabolic androgenic steroid (AAS) use;
(3) the biological basis, especially the
neuroendocrine and hormonal contributions,
to eating and substance use disorders.
Cognitive Behavioral Therapy-Enhanced: A Tailored Treatment
Model for College Women Experiencing EDNOS
Laura H. Choate, Ed.D., LPC, NCC
Louisiana State University
Correspondence should be addressed to: Laura Choate, Counselor Education, 122 Peabody Hall, Louisiana State University, Baton Rouge, LA 70803 (e-mail: [email protected])
T
here is a high prevalence of maladaptive eating practices, weight concerns, and actual eating disorders
in college women, with between 25-40 percent of college women experiencing problems that include extreme
worries about body image, excessive weight management strategies, and perceived out of control eating episodes
(Bishop, Bauer, & Baker, 1998; Schwitzer, Rodriguez,Thomas, & Salimi, 2001).While eating-related concerns are also
increasingly present in college men, women remain disproportionately affected by these problems (Hudson, Hiripi,
Pope, & Kessler, 2007). For the purposes of this article, therefore, only college women’s treatment needs are addressed.
The statistics noting a high prevalence
of eating-related problems in the college
population are not surprising given
current cultural standards regarding the
importance of thinness and beauty for
young women. In addition, campus
environments can serve to magnify
pressures for college women to compare
themselves with same age peers
regarding thinness and attractiveness.
They are often involved in social groups
in which other women are regularly
engaging in excessive dieting,
exercising, bingeing, and purging,
thus modeling and normalizing
maladaptive eating practices.
Developmentally, many women are
at a stage in which their search for
identity centers around a tension
between a desire for increasing
autonomy and a need for connections
with family, peers, and romantic
relationships. Further, due to cultural
messages regarding women’s success,
PERSPECTIVES • SUMMER 2012
college women often also place great
pressure on themselves to achieve in
multiple areas: to excel in academics and
secure a successful career, have a perfect
appearance, and attract and maintain a
romantic relationship (Hinshaw, 2009).
In turn, many women cope with these
powerful pressures through binge eating
or through attempts to control their
weight and shape (Choate, 2011).
Although some women are able to
resist or challenge these pressures to
achieve the thin ideal, many young adult
women experience dissatisfaction with
their bodies (Cash & Hrabosky, 2004).
A subset of women with body image
dissatisfaction subsequently develop
symptoms which meet the criteria for
one of the full-syndrome DSM-IV-TR
eating disorders: Anorexia Nervosa (AN),
Bulimia Nervosa (BN), and Eating
Disorders Not Otherwise Specified
(EDNOS). Of college women who
develop eating disorders, the vast
majority experience a constellation of
symptoms that fall under the EDNOS
classification (Fairburn & Bohn, 2005;
Schwitzer et al., 2008;Wonderlich,
Joiner, Keel,Williamson, & Crosby,
2007). Because EDNOS is the most
widely experienced eating disorder
among college women, the purpose of
this article is to present a summary of
CBT-E, a focused treatment model
for working with college women
experiencing EDNOS.
College Women
and EDNOS
Researchers have demonstrated
that women with EDNOS frequently
have significant impairment, often
experiencing similar problems and levels
of distress as those with AN or BN
(Stice, Killen, Hayward, & Taylor, 1998;
Walsh & Garner, 1997). In addition, the
majority of clients with eating problems
fluctuate frequently between eating
disorder diagnoses, so that clients often
migrate between AN, BN, and EDNOS
(Fairburn, 2008). Further, a recent
large-scale study indicates that EDNOS
mortality rates are similar to rates for
AN, indicating the potential severity of
this disorder (Crow, Peterson, Swanson,
Raymond, Specker, Eckert, & Mitchell,
2009).
As identified by Schwitzer and
colleagues (2001; 2008), college women
who experience EDNOS engage in
frequent binge eating and high levels
of exercise for weight control; however,
they do not generally engage in
compensatory behaviors like vomiting
or laxative use (as in BN) or overly
restrictive eating (as in AN). In
addition, college women with EDNOS
experience significant body dissatisfaction,
drive for thinness, overvaluation of
appearance, rumination of eating and
weight management, unstable selfevaluation, stress, anxiety, depression,
perfectionism, fears related to maturity
and self-sufficiency, and struggles with
functioning autonomously in the adult
world (Schwitzer et al., 2001). As is
demonstrated from this profile, college
women with EDNOS experience
significant reductions in their quality of
life, and counselors need the knowledge
and skills to provide effective treatment
for these concerns.
Cognitive Behavioral
Therapy-Enhanced Model
CBT has emerged as the gold standard
treatment model for understanding and
treating eating disorders (APA, 2006;
Wilson, Grilo, & Vitousek, 2007)
and there is evidence that clients
experiencing EDNOS will respond well
to an adaptation of CBT (Wilson et al.,
2007).The standard CBT treatment was
recently reformulated and enhanced
by Fairburn (CBT-E; 2008) so that it
now takes a transdiagnostic approach to
the conceptualization and treatment of
eating disorders.While less research has
been conducted to date regarding the
newer CBT-E version, recent trials
indicate its effectiveness (Byrne,
Fursland, Allen, & Watson, 2011;
Fairburn, Cooper, Doll, O’Connor,
Bohn, Hawker,Wales, & Palmer, 2009).
Central to CBT-E is its model for
understanding the maintenance of the
disordered eating cycle (Fairburn, 2008).
According to the model, a client may
learn to over-evaluate the importance
of weight and shape in determining
her sense of self-worth.This belief is
reinforced in Western cultures as young
women receive cultural messages
idealizing an unrealistically thin,
attractive appearance. Over time, the
client internalizes the thin ideal as the
most important determinant of her
PAGE 11
worth and value as an individual.
In efforts to attain this ideal, she may
engage in chronic dieting and attempts
to control her weight and shape.
Because of the body’s response to
dietary restraint, however, restriction
is not generally sustainable over a long
period of time. Eventually she will
experience a sense of deprivation and
loss of control that will result in binge
eating. In addition to physiological urges
to binge-eat, binges can also serve as
a way to regulate emotions or modify
negative mood states (Waller et al.,
2007). In individuals with BN, binge
episodes are followed by attempts to
purge the body of unwanted calories,
usually through vomiting, laxative, or
diuretic abuse. Schwitzer’s and
colleagues’ (2001; 2008) research
indicates that college women with
EDNOS are less likely to engage in
these types of behaviors but may turn
to excessive exercise as a compensatory
mechanism. Regardless of whether or
not calories from the binge are purged,
the client experiences a sense of failure
for losing control and will resolve to
work even harder to maintain her diet/
exercise routine in the future. Over
time, the client feels trapped in a cycle
in which she fails in her efforts to reach
her ideal weight and shape, so that her
attempts for control that were intended
to improve her self-esteem contribute
to increased feelings of failure (Fairburn,
2008).
CBT-E Tailored
Treatment Guidelines
CBT-E is focused on the present
and emphasizes the reduction of
maladaptive eating behaviors before
targeting a change in thoughts or
attitudes (Pike, Loeb, & Vitousek, 1996).
While the reader is referred to Fairburn
(2008) for the entire treatment protocol
(see also Choate, 2010 for a summary
of CBT treatment for young women
experiencing EDNOS), it is beneficial
to individualize the CBT-E approach so
that it emphasizes treatment components
that are most relevant to a particular
client’s symptoms and concerns
(Ghaderi, 2006).Therefore, while the
primary CBT-E treatment components
are included here, the summary is
tailored to those areas most specific to
A PROFESSIONAL JOURNAL OF THE RENFREW CENTER FOUNDATION
the treatment needs of college women
experiencing EDNOS. A description of
the four phases of treatment is outlined
next.
Phase One
It is suggested that counselors conduct
Phase One sessions twice weekly over
a four-week period. Phase One begins
with an assessment of the client’s eatingrelated concerns (see Fairburn, 2008 for
recommended assessment instruments
and a guide to clinical interviews).
In addition, the issues described in the
sections below should be addressed
during Phase One.
Motivation and Commitment
Schwitzer and colleagues (2001)
report that college women with
EDNOS are often resistant to seeking
help and try counseling with several
counselors without ever persisting
in a counseling relationship. When they
do seek counseling, they fear that
counselors will pressure them to gain
weight (Vitousek,Watson, & Wilson,
1998).The initial goal for counselors
then will be twofold: to create a
therapeutic alliance in which the client
feels validated and safe in disclosing her
eating problems, and to enhance
motivation and commitment to
changing her eating patterns and
attitudes (Constantino, Arnow, Blasey,
& Agras, 2005).
The counselor can first validate the
client’s feelings of anxiety about being
forced to gain weight while also helping
her to focus on the potential benefits of
change. One way to begin this process
is to emphasize both the pros and cons
of changing her eating-related behaviors
and attitudes so that the client can begin
to recognize that it is in her best interest
to make positive changes in this area
(Miller & Rollnick, 1991). As a college
student, she is likely to be interested in
both shorter-and longer-term goals, so
she can be asked to articulate her goals
for the future and to examine her personal
and professional aspirations. She can
then evaluate the likelihood of achieving
these goals if she persists with her current
behaviors and attitudes. In an atmosphere
of support and validation, the client
begins to realize that she has a choice in
making steps to improve the quality of
her life, and she will gradually become
more invested in the counseling process.
Provide Psychoeducation
To instill confidence in the CBT-E
approach, an overview of the treatment
should be provided in early sessions.
For many college women, the structured
treatment approach may be appealing to
those who feel out of control and need
guidance in establishing boundaries
around their eating and in their lives.
For others who are learning to exert
independence through rebelling against
rules and authority, the approach might
appear too restrictive. For these women,
more time can be spent on motivational
issues so that they perceive change as their
choice and in their own best interest.
As another part of psychoeducation,
the counselor should emphasize the
importance of weekly weighing, selfmonitoring, and other homework
assignments that are crucial to the
success of CBT-E (Fairburn, 2008). In
addition, the counselor should provide
education about the CBT-E model for
eating disorders. As the client learns
about mechanisms that maintain her
disordered eating, it is helpful for the
counselor to create a personalized
diagram to help her view the cycle in
a more objective manner. Further, it is
helpful for counselors to provide
information about such topics as the
consequences of extreme dieting and
the ineffectiveness of vomiting in
promoting weight loss.To reinforce this
information, the book Overcoming
Binge Eating (Fairburn, 1995) is also
recommended as reading for clients.
Further, clients might also benefit from
information on nutrition and health
(APA, 2006).
Introduce regular eating patterns
In Fairburn’s treatment manual (2008),
introducing a pattern of regular eating
is the most important CBT component.
By eating on a regular schedule, the
client has more available energy for
other tasks, and when she is not
experiencing hunger or deprivation,
her urges to binge are highly reduced.
Further, as she eats regularly (and not
according to a restrictive diet), she learns
that this does not cause her to gain
PAGE 12
weight.To normalize eating, clients are
instructed to plan and eat three meals
per day plus two snacks, with no more
than a 4-hour interval allowed between
eating. If necessary, counselors can assist
clients in planning their eating routine,
as many college women with EDNOS
may have difficulty in planning meals
and snacks that do not involve restricting
or bingeing. As many college women
live in settings with little structure or
time for well-planned meal choices, this
aspect may be particularly challenging;
the client may benefit from a referral to
a nutritionist, if one is available.
During the next several sessions, the
client can begin to develop a list of
high-risk situations and then create a
coping plan for each. Because college
women experiencing EDNOS often
engage in excessive exercise as a means
of compensating for binges (Schwitzer et
al., 2001; 2008), counselors can encourage
strategies for managing situations that
generally lead to excessive exercise. For
college women who live in settings in
which over-exercising is frequent and
highly reinforced, there is a need to
refrain from visiting crowded campus
fitness centers after meals. Instead a client
might benefit from enlisting the help of
a supportive friend who can make plans
with her for scheduled post-meal
activities that do not involve exercise
to burn unwanted calories.
Phase Two
Phase Two begins after the first four
weeks of counseling sessions.This is a
transitional stage comprised of two
sessions during which the counselor
reviews client progress to date, identifies
any obstacles, and decides upon the
treatment components that need to be
addressed in Phase Three. At this stage it
is important for the counselor to assess
for client improvement, as early response
to CBT is a clinically significant
predictor of positive treatment outcome
(Wilson et al., 2007). If she is not
making progress, the counselor may
need to spend additional time on the
components of Phase One, revisit the
client’s commitment to change, or
abandon the CBT approach in the
hopes that a different treatment will be
more effective.
PERSPECTIVES • SUMMER 2012
Phase Three
Phase Three is generally comprised
of eight sessions and begins with a focus
on the client’s beliefs and behaviors
regarding the over-evaluation of weight
and shape. To determine the importance
of this area in her life, the client can
draw a self-evaluation pie chart. She is
asked to think about all areas of her life
upon which she judges herself. She
can fill in the pie with appropriately
proportioned slices (Fairburn, 2008;
Waller et al., 2007). As she examines her
pie chart, she can better see the need for
reducing the proportion that is related to
weight and shape and for increasing the
proportions in other areas.To reduce
the importance of weight and shape,
cognitive restructuring is helpful in
identifying and changing belief patterns
in this area.
To begin developing other life
areas, the counselor can encourage the
client to identify strengths in multiple
life dimensions, including spiritual,
intellectual, social, and physical
competence (Choate, 2008; Myers &
Sweeney, 2005). As the client learns to
view her identity as more than just her
appearance, she can dedicate her time
and energy to more meaningful activities,
pursuits, and goals.When she begins to
appreciate her strengths, engage in
activities beyond the pursuit of the thin
ideal, focus on her goals for collegiate
life and her career aspirations after
college, and accept and value herself, she
will be less likely to engage in chaotic
eating and bingeing patterns.
Schwitzer and colleagues (2008)
report that college women with
EDNOS typically experience problems
related to perfectionism and an unstable
self-evaluation which is overly tied to
weight and shape. If a client’s beliefs
in these areas appear to be significant
obstacles to her progress in treatment,
Fairburn (2008) also includes a treatment
protocol to address these additional areas
of focus that can be included in this stage.
If a client is experiencing perfectionism
(i.e., over-evaluation of achievement in
determining self-worth, rigorous pursuit
of personally demanding standards)
and/or low self-esteem (i.e., pervasive
negative view of self, negative bias in
viewing the self and the world, little
perceived value as a person) then the
counselor can help her view herself
in a more realistic, balanced manner,
appreciating both her strengths and
her areas for growth. She can begin
to engage in more performance-free,
rewarding, fun activities that she might
have missed out on previously due
to her focus on achievement, dieting,
weight, and shape. She can also examine
her beliefs that she has to achieve high
standards in all areas in order to have
worth and value as a woman, so that she
can start to recognize the futility of
trying to fulfill all roles at one time
(Fairburn, 2008).
Another yet important aspect to
address in Phase Three is reducing
dietary restraint.Whereas in Phase One
the goal was to normalize eating times,
a goal in Phase Three is to eliminate
dieting by addressing both the type and
amount of food eaten. She can first
identify any dietary rules she has
created, begin a plan to intentionally
break each rule, and then determine
alternative ways to approach eating.
Another step is to create a hierarchy of
typically avoided or “forbidden” foods,
and progressively incorporate them into
meals, beginning with the least
threatening and working up the
hierarchy towards the consumption of
foods perceived as the most anxietyproducing (Wilson et al., 1997).The
client is also encouraged to examine
the amount of food she eats throughout
the day. College women experiencing
EDNOS may often limit their food
intake during the day, avoiding meals
as they rush between classes and/or
work schedules, then overeat or binge
in the evenings due to feelings of stress,
hunger, and deprivation. At this point
the counselor can then assist her with
planning and eating well-balanced meals
and snacks throughout the day that will
provide adequate energy for her to
function optimally.
The final aspect of Phase Three is
addressing the ways in which a client
manages stressful events and negative
moods, as these often serve as triggers
for continued binges. Many clients with
disordered eating have poor coping
skills for dealing with distress related to
the academic demands of college life,
relationships with friends, family, or
romantic partners, or difficult life
PAGE 13
transitions. Instead of coping directly
with the situation or feelings, they have
learned to use eating as a way to avoid
or reduce negative emotional states
(Waller et al., 2007). Coping skills
development will be helpful for the
client in managing stressful events
instead of turning to her maladaptive
eating practices.
Phase Four
The fourth and final phase of CBT is
to explore termination and to encourage
the client to independently use the
CBT strategies she has learned. This
phase is generally comprised of three
sessions, scheduled once every other
week. To prepare for termination, a
client needs to summarize the progress
she has already made in changing her
eating- and shape-related attitudes
and behaviors and to identify those
components she will need to target
in order to continue making progress
towards her goals (Fairburn, 2008).
CONCLUSIONS
The CBT-E approach to treatment for
EDNOS can be effective in helping
college women to normalize eating and
to decrease the over-evaluation of weight
and shape. As with any approach, there
are several limitations to this model.
First, little research has been conducted
to examine the differential impact of
CBT-E for individuals from diverse
racial/ethnic minority backgrounds
(Cummins & Lehman, 2007). A second
limitation is the relatively low treatment
response rate; although no studies have
examined the client recovery rate for
EDNOS in particular (Fairburn & Bohn,
2005), only 30-50 percent of clients with
BN report full recovery at the end of
CBT treatment (Wilson et al., 2007).
Although it is the most effective approach
available, it might not be effective for
certain individuals. For women who do
not respond to CBT-E, recent research
indicates the use of Interpersonal
Psychotherapy (IPT) or DBT as effective
treatments for eating disorders (APA,
2006;Wilson et al., 2007). For further
reading regarding these approaches, refer
to the IPT (Wilfley, MacKenzie,Welch,
Ayers, & Weissman, 2000) and DBT (Safer,
Telch, & Chen 2009) manuals. In summary,
A PROFESSIONAL JOURNAL OF THE RENFREW CENTER FOUNDATION
despite these limitations, CBT-E is
recommended as a first-line treatment
for disordered eating and has the greatest
likelihood of treatment success for
EDNOS (Wilson et al., 2007). CBT is
likely to help college women with
EDNOS to improve the quality of their
lives as they normalize their eating patterns,
reduce binge eating, and begin to change
their thinking about the importance of
appearance as the primary criterion for
judging self-worth.
REFERENCES
American Psychiatric Association (2006).
Practice guideline for the treatment of
patients with eating disorder (revision).
American Journal of Psychiatry. 157, 1-39.
Bishop, J. B., Bauer, K.W., & Baker, E.T.
(1998). A survey of counseling needs of
male and female college students.
Journal of College Student Development, 39,
205-210.
Crow, S. J., Peterson, C.B., Swanson, S.
A., Raymond, N.C., Specker, S., Eckert,
E.D., Mitchell, J. E. (2009). Increased
Mortality in Bulimia Nervosa and Other
Eating Disorders. American Journal of
Psychiatry, 166, 1342-1346.
Cummins, L.H., & Lehman, J. (2007).
Eating disorders and body image
concerns in Asian-American women:
Assessment and treatment from a
multicultural and feminist perspective.
Eating Disorders, 15, 217-230.
Fairburn, C. G., Cooper, Z., Doll, H.A.,
O’Connor, M.E., Bohn, K., Hawker,
D.M.,Wales, J. A., Palmer, R. L. (2009).
Transdiagnostic Cognitive-Behavioral
Therapy for Patients with Eating
Disorders: A Two-Site Trial with
60-Week Follow-Up. American Journal
of Psychiatry, 166, 311-319.
Fairburn, C. G. (2008). Cognitive
behavior therapy and eating disorders.
New York: Guilford Press.
Byrne, S.M., Fursland, A., Allen, K. L.,
Watson, H. (2011).The effectiveness of
enhanced cognitive behavioural therapy
for eating disorders: An open trial.
Behaviour Research and Therapy, 49,
219-226.
Fairburn, C. G., & Bohn, K. (2005).
Eating disorders NOS (EDNOS):
An example of the troublesome
“Not otherwise specified” (NOS)
category in DSM-IV. Behavior
Research and Therapy, 43, 691-701.
Cash,T. F. & Hrabosky, J. I. (2004)
Treatment of Body Image Disturbances.
In J. K.Thompson (Ed.), Handbook of
Eating Disorder and Obesity.
(pp. 515-541). Hoboken, NJ:
John Wiley & Sons, Inc.
Fairburn, C. G., (1995). Overcoming binge
eating. New York:The Guilford Press.
Choate, L. (2011). Negotiating cultural
pressures: A treatment model for binge
eating in adolescent girls. Women and
Therapy, 34, 377-393.
Choate, L. H. (2010). Treatment for
college women experiencing EDNOS:
A Cognitive Behavioral Therapy model.
Journal of College Counseling, 13, 73-86.
Choate, L. H. (2008). Girls’ and
women’s wellness: Contemporary issues and
interventions. Alexandria,VA:
American Counseling Association Press.
Constantino, M. J., Arnow, B.A., Blasey,
C., & Agras, S.W. (2005).The association between patient characteristics and
the therapeutic alliance in cognitivebehavioral and interpersonal therapy for
bulimia nervosa. Journal of Consulting and
Clinical Psychology, 73, 203-211.
Ghaderi, A. (2006). Does individualization matter? A randomized trial of
standardized (focused) versus
individualized (broad) cognitive
behavior therapy for bulimia nervosa.
Behaviour Research and Therapy, 44,
273-288.
Hinshaw, S. (2009). The Triple Bind:
Saving our Teenage Girls from Today’s
Pressures. New York: Ballentine Books.
Hudson, J. I., Hiripi, E., Pope H. G.,
Kessler, R.C. (2007).The Prevalence
and Correlates of Eating Disorders in
the National Comorbidity Survey
Replication. Biological Psychiatry, 61,
348-358.
Miller,W. R., & Rollnick, S. (1991).
Motivational interviewing: Preparing people
to change addictive behavior. New York:
Guilford Press.
PAGE 14
Myers, J. E., & Sweeney,T. J. (Eds.).
(2005) Counseling for wellness:Theory,
research, and practice. Alexandria,VA:
American Counseling Association Press.
Pike, K. M., Loeb, K., & Vitousek, K.
(1996). Cognitive-Behavioral Therapy
for Anorexia Nervosa and Bulimia
Nervosa. In J. K.Thompson (Ed.),
Body Image, Eating Disorders, and Obesity:
An integrative guide for assessment and
treatment (pp. 253-302).Washington, DC:
American Psychological Association.
Safer, D.L.,Telch, C. F., & Chen, E.Y.
(2009). Dialectical Behavior Therapy for
Binge Eating and Bulimia. New York:
Guilford Press.
Schwitzer, A.M., Hatfield,T., Jones,
A.R., Duggan, M. H., & Winninger, A.
(2008). Confirmation among
college women:The Eating Disorders
Not Otherwise Specified diagnostic
profile. Journal of American College Health,
56, 607-615.
Schwitzer, A. M, Rodriguez, L. E.,
Thomas, C., & Salimi, L. (2001). The
Eating Disorders NOS diagnostic profile
among college women. Journal of
American College Health, 49, 157-166.
Stice, E., Killen, J. D., Hayward, C.,
& Taylor, C. B. (1998). Support for the
continuity hypothesis of bulimic
pathology. Journal of Consulting and
Clinical Psychology, 66, 787-790.
Vitousek, K.,Watson, S., & Wilson,
G.T. (1998). Enhancing motivation for
change in treatment – resistant eating
disorders. Clinical Psychology Review, 18,
391-420.
Waller, G., Cordery, H., Corstorphine,
E., Hinrichsen, H., Lawson, R.,
Mountford,W., & Russel, K. (2007)
Cognitive Behavior Therapy for Eating
Disorders. New York: Cambridge
University Press.
Walsh, B.T., & Garner, D. M. (1997).
Diagnostic issues. In D. M. Garner &
P. E. Garkinkel (Eds.), Handbook of
treatment for eating disorders (pp.25-34).
New York:The Guilford Press.
Wilfley, D. E., MacKenzie, K. R.,Welch,
R. R., Ayers,V. E., & Weissman, M. M.
(2000). Interpersonal Psychotherapy for
Group. New York: Basic Books.
PERSPECTIVES • SUMMER 2012
Wilson, G.T., Grilo, C. M., & Vitousek,
K. M. (2007). Psychological treatment
of eating disorders. American Psychologist,
62, 199-216.
Wilson, G.T., Fairburn, C. G., & Agras,
W.S. (1997). Cognitive-behavioral
therapy for bulimia nervosa. In D.M.
Garner, & P. E. Garfinkel (Eds.),
Handbook of Treatment for Eating Disorders,
Second Edition (pp. 67-93). New York:
The Guilford Press.
Wonderlich, S. A., Joiner,T. E., Jr., Keel,
P.,Williamson, D. A., & Crosby, R. D.
(2007). Eating disorder diagnoses:
Empirical approaches to classification.
American Psychologist, 62, 167-180.
Laura H Choate,
Ed.D., LPC, NCC
is an associate professor
of counselor education
at Louisiana State
University. Her research
interests include counseling
issues and interventions for
girls and women, including the prevention and
treatment of eating disorders. She is the guest
editor of a special issue on the prevention and
treatment of eating disorders which will appear
in the Journal of Counseling and
PAGE 15
Development in Summer, 2012. She is
the author of the book, Girls and Women’s
Wellness: Contemporary Counseling
Issues and Interventions (American
Counseling Association Press, 2008) and
is currently writing the forthcoming book
Counseling Girls in Distress:
A Counselor’s Guide to Treatment
and Prevention (Springer Publications),
and an edited book, Eating Disorders
and Obesity: A Counselor’s Guide to
Treatment and Prevention (American
Counseling Association Press).
Is Bioelectrical Impedance Analysis (BIA)
Efficacious in Monitoring Body Composition Changes During
Treatment of Restrictive Eating Disorder Patients?
Charles F. Saladino, Ph.D.
I
n the United States, approximately 24 million people of all ages and genders suffer from some form
of an eating disorder. (Nat. Assoc. Anorex. Nerv. Assoc. Disord, 2011).The mortality rate associated with anorexia
nervosa is 12 times higher than the death rate associated with all causes of death for females 15-24 years old. In
addition, almost 50 percent of people with eating disorders meet the criteria for depression, and only 35 percent of
those receiving any treatment are treated at a facility that specializes in such afflictions (Nat. Assoc. Anorex. Nerv. Assoc.
Disord., 2011). Clearly, treatments for eating disorder patients must emphasize appropriate restoration of the patients’
overall mental and physical health, including the acquisition of proper body composition.
This report considers the efficacy of
utilizing BIA as a potential technique to
evaluate body composition during the
weight gain process in restrictive-eating
disorder patients.This is important in
that improper dietary intake can have
profound metabolic effects (Sullivan,
1995; Noordenbox, 2002; Nicholls et al.,
2004; Dixon et al. 2007).
BIA is an inexpensive and relatively
simple method for measuring body
composition, first applied by Hoffer et
al., (1969) to measure total body water
and then by Luskaski et al. (1985) to
determine nutritional status. Basically,
the instrument uses electrodes to send
a harmless very-low level of electric
current through the body. Whereas fatty
tissue is low in water content and does
not conduct electricity well, lean body
mass (muscle tissue) is more than 70
percent water and does conduct an
electric current relatively efficiently.
Briefly, BIA measures body fat (FM)
(which optimally ranges up to about 25
percent in women and 20 percent in
men), as well as lean body mass, the sum
of Body Cell Mass(BCM) plus Extracellular Mass(ECM). (Ellis, 2001; Kyle
et al., 2004). Lean body mass is also
referred to as fat free mass (FFM). In
addition, the instrument also measures
body mass index (BMI) and intracellular
and extracellular water.
In general, aging is associated with a
loss of lean body mass and strength and
the elderly can sometimes experience
replacement of some muscle mass with
fat, but with a stable body weight
(Gallagher et al, 2000; Song et al., 2004),
even though weight gain in the young
adult into the mid-life years shows an
increase in both fat and muscle mass.
In addition, intra-abdominal visceral fat
and waist circumference often increase
with age at a faster rate than total body
weight (Hughes et al., 2004, Snijder et
al., 2006; Fantin et al., 2007); and BMI
does not take fat distribution into
account (Goodpaster et al, 2005;
Ramsay et al., 2006). BIA data can be
used to assess actual body composition
and thus guide nutritional approaches
to metabolic illness. Just as early
detection of body composition changes
resulting from certain diseases allows for
early intervention treatments, it seems
clear that the restrictive-eating disorder
patient could benefit from the clinician’s
ability to empirically evaluate body
composition alterations prior to and
during therapy, particularly given the
metabolic and psychological complexity
of anorexia and bulimia.
A PROFESSIONAL JOURNAL OF THE RENFREW CENTER FOUNDATION
Studies
with
BIA
Mika et al. (2004) correctly pointed
out that assessing changes in body
composition and nutritional status is
critical for proper nutritional
management during refeeding
treatments. Utilizing BIA technology,
they evaluated 21 female adolescents
with anorexia nervosa (AN) with an
initial BMI of 15.5 (15.5 + 1.1 kg/m2)
and 19 normal-weight, age-matched
female controls, each four times
between weeks 3 - 15 of refeeding with
a hyperenergetic diet. By this method,
the researchers concluded that changes
observed in the extracellular mass
(ECM)/body cell mass (BCM) index
were due to an increase in BCM, and
that multi-frequency phase-sensitive
BIA would be a promising tool for
assessment of nutritional status and body
composition in AN patients.
An interesting comparison was made
by Mattar et al. (2011) between BIA
and Dual x-ray absorptiometry (DXA)
to measure FFM and FM in 50 female,
underweight patients with anorexia
nervosa. It was concluded that the
best estimates of FFM and FM in the
anorexic study group was when the
Deurenberg equation, one of several
different formulae for computing FFF,
was used with BIA, because it took into
account height, weight, and age, and it
was applicable in adolescents and adults
ages 13.4 to 36.9 years-old and for BMI
values of 12.8 - 21.
Ghosh et al. (1997) evaluated an
inexpensive hand-held BIA instrument
for use at patient bedside.They compared
measures of lean body mass in
comparison to DXA measures in
potentially malnourished patients.
Body composition analysis was obtained
from 17 patients with eating disorders, 7
with chronic alcoholic pancreatitis, and
18 with inflammatory bowel disease.
The results clearly indicated that in thin
and non-obese adults, an accurate two
compartment (lean body mass and fat
mass) measurement could be made in
ten minutes using this hand-held BIA
machine.
In a study utilizing BIA, anthropometry
and DXA to assess body composition,
Bruni et al. (2011) found that subjects
with eating disorders had a lower BMI
and fat mass (measured with both
techniques) compared to patients with
functional hypothalamic amenorrhea.
Leptin levels were positively associated
with fat mass and also with body cell
mass indexed to height and BIA phase
angle parameters (an expression of the
active lean body compartment and
cellular health). This study certainly
accentuated the value of BIA, which was
corroborated with DXA. In a separate
report using the same subjects, Bruni
et al. (2011) demonstrated that a
multivariate analysis model confirmed
the utility of integrating endocrine data
with the study of body composition;
and they reported that BIA proved to
be a useful clinical alternative to DXA,
especially when considering body cell
mass and phase angle.
In an interesting study conducted by
Vaz et al. (2003) body composition was
analyzed in a group of patients fulfilling
DSM-IV criteria for bulimia nervosa
(BN). Forty three patients with prior
AN (BN-AN group) and 61 without
this history (BN-nonAN) were evaluated
for height and weight, abdominal
diameter, body circumferences, skinfold
thickness, and BIA parameters.
The results showed that more than 40
percent of the BN-AN group showed
a BMI of < 20, as well as lower muscle
mass, and a higher percent of
extracellular water. However, these
differences were not evident in the
second part of the analysis, when only
patients with a normal weight range
were compared. This indicated that a
large number of BN patients tend to
retain some clinical traits of the previous
condition, remaining in a “subclinical
status.” In other words, they were
thinner and had the tendency to remain
at a lower weight. Importantly, however,
this tendency no longer existed when
patients had achieved a normal weight.
This raised interesting questions
regarding the boundaries between BN
and AN and reinforces the importance
of monitoring weight and body
composition of patients with either
disorder.
Rigaud et al.(2000) examined the
metabolic expression of extreme
starvation in five very malnourished
patients (BMI = 9.77 +.01) on the
PAGE 16
verge of death vs. 16 less-malnourished
AN patients. Resting energy
expenditure (REE) was determined
by indirect calorimetry, and body
composition was measured by
anthropometry and BIA. At the start of
refeeding, the REE was high in all 5 of
the malnourished patients and associated
with almost no fat mass, high urinary
nitrogen, low serum fatty acids and low
to normal catecholamines, insulin, and
thyroid hormone values. During the
first 2 - 4 weeks of refeeding of the
extremely malnourished patients,
REE decreased, whereas fatty acid
concentrations increased in the four
remaining patients (one having died).
REE was low in the AN patients at
the start of refeeding and increased
thereafter, along with urinary nitrogen
output. The reason for the higher
REE and protein catabolism was not
specifically known, but obviously could
have been due to consumption of the
final muscle mass and to diseased
membranes in those malnourished
patients near death.
Many methods of measuring body
composition are time-consuming
and require equipment that is often
unavailable; but BIA is simple and
inexpensive and can differentiate
between lean and fat tissues. Studying
38 anorexic females with highly variable
BMI, Hannan et al.(1991), concluded
from the data that the BIA technique
compared favorably with other
established methods, even in AN patients
with a very low BMI. Other studies,
however, caution that BIA may have
limited utility with some patients with
AN (Haas et al, 2012).
Although the various body
composition studies that have been
presented thus far focus on anorexia, an
interesting and recent report by Marra
et al. (2009) presented data regarding
body composition in underweight ballet
dancers and constitutionally lean females.
The study utilized phase angle
measurements (a bioimpedance variable
related to body cell mass) to ascertain
whether this parameter differed between
the two groups. Thirty AN patients, 10
constitutionally lean individuals, and
15 classic dancers were evaluated by
skin fold thickness and BIA. The results
PERSPECTIVES • SUMMER 2012
indicated that the BIA-derived phase
angle (an indicator of cellular health and
integrity) discriminated between
different forms of underweight, and
that it is an effective marker to detect
qualitative changes in body composition.
In a study by Saladino et al. (2009),
which assessed 79 restrictive eating
disorder patients receiving a modified
Mediterranean-style diet, it was
observed that 37 percent gained body
cell mass interpreted from BIA as lean
body mass, and an additional 39 percent
gained lean body mass and fat mass from
this diet (p <0.05). Importantly, the BIA
data showed that the fat mass acquired
by this second group of patients still
allowed them to achieve a lean body
mass to fat ratio of 80/20 - 75/25.
The remaining study group lost lean
body mass. Of potential significance,
body fluid changes elucidated by BIA
appeared to have indicated early onset of
Refeeding Syndrome (Kraft et al., 2005)
in two of the patients, although this was
not definitely ascertained.
Of course it is well-recognized that
the issues which lay at the heart of
restrictive eating disorder patients are
quite complex. This is exemplified by
the work of Van Wymbeleke et al. (2004)
who studied 87 female AN patients
and included BIA to assess body
composition. During the treatment
period, it was observed that by day eight,
resting energy expenditure increased
significantly (13.4percent, p <0.01),
based upon an increase in fat-free mass,
and that the ratio of REE/FFM
remained high thereafter. However,
by multivariate analysis, they concluded
that the rise in this ratio observed during
refeeding was significantly related to
energy intake, anxiety, abdominal pain,
and depressive mood; and they also
noted a significant rise in the REE/
FFM ratio with physical activity and
cigarette smoking. This rise in REE
leveled off after recovery from AN.
This strongly suggests that a great
many variables affect the results and
interpretation of even efficacious BIA
data, and that analysis of such data must
be careful, thorough, and integrated with
as much knowledge about the patient as
possible.
PAGE 17
SUMMARY
REFERENCES
The studies presented in this review,
along with the vast experience of
clinicians and researchers, accentuate
the metabolic and psychological
complexity of understanding and
treating restrictive eating disorder
patients. It seems clear that assessing
body mass composition in these patients
would be an important component of
diagnosis and treatment options; and it
is suggested here that such an evaluation
would ascertain whether or not the
acquisition of body mass during
refeeding would be metabolically
appropriate - ideally achieving an
approximate 20/80 percent - 25/75
percent fat/lean body mass ratio.
In addition it is reasonable to suggest
that utilizing BIA techniques to achieve
this assessment could be efficacious and
advantageous in patients with eating
disorders. Furthermore, assessing body
composition is also important, because
weight changes do not necessarily reflect
specific changes in body compartments
(including fat free mass and fat mass).
Of course, many patients with eating
disorders have other psychiatric and
behavioral comorbidities such as
substance abuse and dependence that
can confound data obtained for a
research study or a treatment regimen.
However, by utilizing a technique like
BIA, clinicians and researchers have the
advantage of using each patient as their
own “control” which could potentially
allow for a more effective, individualized
nutrition regimen according to the body
composition changes observed during
their treatment period. In addition, BIA
can provide information on BMR in
anorexic patients and should be explored
in evaluating other forms of protein
malnutrition. Finally, although it is not
yet proven, BIA can measure body fluid
changes making it theoretically possible
that this diagnostic technique could be
used as an additional tool for detecting
the early onset of Refeeding Syndrome
in patients at risk for this constellation
of metabolic disturbances. Therefore, in
the hands of a qualified clinician with
expertise in instrumentation as well
as human metabolism, it appears that
BIA could be a very useful modality in
the treatment of patients afflicted with
restrictive eating disorders.
Bruni,V., Dei, M., Morelli, C., Schettino,
M., Balzi, D., Balzi, D., & Nuvolone, D.
( 2011). Body Composition Variables
and Leptin levels in Functional
Hypothalamic Amenorrhea and
Ammenorreah Related Eating
Disorders. J. Ped. Adolesc. Gynecol., 24,
347-52.
Dixon, J. B., Boyd, J. B., Strauss, J. G.,
Laurie, C, and O’Brien, P. E. (2007).
Changes in Body Composition with
Weight Loss: Obese Subjects
Randomized to Surgical and Medical
Programs. Obesity, 15, 1187-98.
Ellis, K. J. (2001). Selected Body
Composition Methods Can Be Used in
Field Studies. J. of Nutrition, 131,
1589S-95S.
Fantin, F. Francesco,V. D., Fontana, G.
et al. (2007). Longitudinal body
compositional changes in old men and
women: Inerrelationships with
worsening diability. J. Gerontol.
A Biol. Sci. Med., 62, 1375-81.
Gallagher, D., Ruts, E.,Visser, M. et al.
(2000). Weight stability masks
sarcopenia in elderly men and women.
Am. J. Physiol. Endocinol. Metab., 279,
E3660E375.
Goodpaster, B. H., Krishnaswami, S.,
Harris,T.B., et al. (2005). Obesity,
regional body fat distribution, and the
metabolic syndrome in older men and
women. Arch. Intrn. Med., 165, 777-83.
Gosh, S., Meister, D. Cowen, S.,
Hannan,W. J., & Gerguson, A. (1997).
Body Composition at the bedside.
Europ. J. Gastroent. Hepatol., 9, 783-8.
Hannan,W. J., Cowen, S., Freemen, C. P.,
& Shapiro, C. M. (1991). Evaluation of
bioeletrical impedance analysis for body
composition measurements in anorexia
nervosa. Clin. Phys. Physiol. Meas., 12,
93-4.
Hass,V., Riedl, A., Hofman,T., Nischan,
A., Burghardt, R., Boschmann, M., &
Klapp, B. (2012). Bioimpedance and
Bioimpedance Vector Analysis in patients
with Anorexia Nervosa. Europ. Eat
Disord. Rev. (Epub ahead of print),
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Hoffer, E. C., Meador C. K., & Simpson,
D.C. (1969). Correlation of wholebody impedance with total body water
volume. J Appl Physiol, 27, 531.
Hughes,V. A., Roubenoff, R.,Wood, M.,
Frontera,W.R., Evans,W.J. & Fiatarone
Singh, M.A. (2004). Anthropometric
assessment of 10-y changes in body
composition in the elderly. Am J.
Clinical Nutrition, 80, 475-82.
Kraft, M. D., Btaiche, I. F., & Sacks, G. S.
(2005). Review of the Refeeding
Syndrome. Nutrition in Clinical Practice,
20, 625-33.
Kyle, U.G., Bosaeus, I., De Lorenzo,
A.D., Durenberg, P., Elia, M., Gomez,
J. M., Heitmann, B. L., Kent-Smith, L.,
Melchior, J-C., Pirlich, M., Scharfetter,
H., Schols, A. M., & Pichard, C. (2004).
Bioelectrical Impedance Analysis-part 1:
review of principles and methods.
Clin. Nutr., 23, 1226-43.
Lukaski H. C., Johnson P.E., Bolonchuk
W.W., Lykken, G. I. (1985). Assessment
of fat-free mass using bioelectrical
impedance measurements of the human
body. Am. J Clin. Nutr., 41, 810-17.
Marra, M., Caldra, A., Montagnese, C.,
DeFilippo, E., Pasanisi, F., Contaldo, F.,
& Scalfi, L. (2009). Bioelectrical
impedance phase angle in constitutionally lean females, ballet dancers, and
patients with anorexia nervosa. Europ. J.
Clin. Nutrition, 63, 905-8.
Mattar, L. Godart, N., Melchior, J. C.,
Falissard, B., Kolta, S., Ringuenet, D.,
Vindreau, C., Nordon, C., Blanchet, C.,
& Pichard, C. (2011). Underweight
patients with anorexia nervosa:
comparison of bioelectrical impedance
analysis using five equations to dual
X-ray absorptiometry. Clinical Nutrition,
30, 746-52.
Mika, C., Herpetz-Dahlmann, B., Heer,
M, & Holtzkamp, K. (2004). Improvement of Nutritional status as assessed by
multifrequency BIA during 15 weeks
of refeeding in adolescent girls with
anorexia nervosa. J. Nutrition, 134,
3026-30.
National Association of Anorexia
Nervosa and Associated Disorders, Eating
Disorder Statistics, accessed May 7, 2012,
http://www.anad.org/get-information/
about-eating-disorders/eating-disordersstatistics/
Nicholls, D.,Wells, D. J., Singhal, A, &
Stanhope, R. (2004). Validation of the
Dutch Eating Behaviour Questionnaire
parent version (DEBQ-P) in the Italian
population: a screening tool to detect
differences in eating behaviour among
obese, overweight and normal-weight
preadolescents. European Journal of
Clinical Nutrition, 58, 1217-22.
Noordenbox, G. (2002). Characteristics
and Treatment of Patients with Chronic
Eating Disorders. International Journal of
Eating Disorders, 10: 15-29.
Ramsay, S. E.,Whincup, P.H., Shaper,
A.G., & Wannamethee, S.G. (2006).
The relations of body composiiton
and adiposity measures to ill health and
physical diability in elderly men. Am. J.
Epidemiol., 164, 459-69.
Rigaud, D., Hassid, J., Meulemans, A.,
Popaud, , A.T., & Boulier, A. (2000). A
paradoxical increase in resting energy
expendature in malnourished patients
near death: the king penguin syndrome.
Am. J. Clin. Nutr., 72, 355-60.
Saladino, C. F. & Dieffenback, S. (2009).
The Use of Bioelectrical impedance to
Monitor Metabolic/Body Composition
Changes Resulting from Dietary
Treatment in Restrictive Eating
PAGE 18
Disorder Patients. Am. Soc. Cell Biol.
49th Ann. Meeting, San Diego, CA,
page 548.
Snijder, M. B., van Dam, R. M.,Visser,
M. & Seidell, J. C. (2006).What aspects
of body fat are particularly hazardous
and how do we measure them? Int. J.
Epidemiology, 35, 83-92.
Song, M-Y., Ruts, E., Kim, J. Janumala, I.,
Heymsfield, S., & Gallagher, D. (2004).
Sarcopenia and increased adipose tissue
infiltration of muscle in elderly African
American women. Am. J. Clin. Nutrition,
79, 874-80.
Sullivan, Patrick. (1995). Mortality in
Anorexia Nervosa. American Journal of
Psychiatry, 152 (7), 1073-4.
Vaz, F. J., Guisado, J. A., & Penas-Lledo,
E. M. (2003). History of anorexia
nervosa in bulimic patients: its influence
on body composition. Int. J. Eat Disord.,
34, 148-55.
Van Wymbeleke,V. Brondel, L. Marcel
Brun, J., & Rigaud, D. (2004). Factors
associated with the increase in resting
energy enpenditure during refeeding in
malnourished anorexia nervosa patients.
Am. J. Clin. Nutr., 80, 1469-77.
Charles F. Saladino,
Ph.D. is Chair of the
Chemistry/Biochemistry
Department at Misericordia
University in Dallas, PA.
He’s a former Director of
Cardiology Research for
20 years at the Nassau
University Medical Center, East Meadow, NY.
PERSPECTIVES • SUMMER 2012
PAGE 19
Group Therapy and Eating Disorders
Cindy James, Ph.D.
E
motional and cognitive insight is often insufficient in producing change in eating disorder patients.
Group therapy provides a unique opportunity for both emotionally corrective nourishing relationships and
behavioral practice of new skills.This article will discuss the clinical challenges in applying evidence based treatment
in the real world practice of group psychotherapy. It will also explore some of the common challenges therapists face
in managing group dynamics and their own countertransference in their group work with eating disordered patients.
My first experience in leading group
therapy for eating disorders was in 1984
as a psychiatric nurse at a private hospital
in Beverly Hills, California. I was one
of the initial team members charged
with designing implementation and
facilitation of groups.We worked 12
hour shifts supervising the meals and
snacks for anorexics and bulimics, hence
I had the experience of seeing first hand
the painful desperation and stubborn
nature of these illnesses. In 1985, I
joined the nursing staff at UCLA
Neuropsychiatric Institute working
on the adolescent unit. I had the
opportunity to lead the eating disorder
group supervised by one of my
mentors, Dr. Michael Strober.
Completing my post-doctoral
fellowship at UCLA, I later assisted in
directing UCLA’s outpatient eating
disorder program.We used several
group therapy formats including process
oriented, psychodynamic groups, family
groups, and an integrative approach of
CBT.
For the last 18 years I have been in
private practice on the east coast with
a focus on eating disorders. I have
found that adding group therapy to my
individual sessions greatly facilitates the
process of healing. I have been using an
integrative approach of CBT, modern
analytic understanding, and now DBT
informed skills training. My interest and
experience in group therapy and treating
eating disorders has developed through
a process of trial and error. My lab has
been my office and following patient
progress over the years. I gauge success
in the relinquishing of symptoms, and
positive progress in their lives outside of
treatment.
Types
of Group Therapy
Many different types of group therapy
have been used in the treatment of patients with eating disorders. The following are brief descriptions of the types of
group therapies I have found to be most
helpful in my work.
• Cognitive Behavior Therapy CBT
(Fairburn, 1995; Agras, et al., 1997)
focuses on normalizing eating
patterns and challenging overvalued
ideas regarding weight and shape.
• Interpersonal Therapy (Klerman
& Weissman, 1993,Wilfey et al.,
2002) focuses on resolving inter-
personal difficulties that maintain
eating disorder pathology.
• Self-psychology models the group
as a whole that provides containing
and mirroring functions to address
self issues, and relational emphatic
failures (Schwartzman 1984; Kohut,
1984).
• Attachment based group therapy
attempts to resolve attachment
insecurities and improve reflective
functioning (Tasca et al., 2006).
• Dialetical Behavioral Therapy
(DBT) has been adapted for use
with BED and BN in both
individual and group formats.
DBT is a skills based approach for
improving emotional awareness and
regulation. Affect regulation models
link negative affect and disordered
eating (Arnow, Kenardy, & Agras,
1992), and conceptualize eating
pathology such as binging,
restricting and purging as
behavioral attempts to control
painful or stressful emotional states
(Linehan & Chen, 2005;Wisniewski
& Kelly, 2003).
• Modern analytic psychotherapy
(Spotnitz, 2004), focuses on the
patient’s narcissistic defenses and
underlying aggression.The modern
analytic approach emphasizes the
use of therapist’s feelings induced by
the group.The therapist works
to join with and reflect upon group
resistances, rather than challenging
them directly.This approach
encourages the expression of
aggressive drives and therapeutic
interventions are intended to
provide emotional communications
to the patient rather than to
promote intellectual insight. Group
members and the therapist will
elicit feelings of rejection, neglect
and envy normally encountered
in interpersonal relationships outside
of group.The therapy involves
training patients “to say anything;”
expressing negative thoughts and
feelings in the group makes it less
likely that they will be acted out in
and outside of group.
Why Group Therapy?
Obsessive dieting and other eating
disorder behaviors often begin as an
attempt to adapt to concerns related to
identity, competence, and emotion
regulation. Research has demonstrated
patterns of personality traits in patients
with anorexia nervosa including
discomfort with change, fear of taking
risks, emotional constriction, shyness,
and negative self-evaluation
(Wonderlich, 2002; Strober &
Goldenberg, 1981; Strober, 1991).
Consequently, it is not surprising that
anorexia usually presents itself during
puberty, the quintessential period of
emotional and physical change. Bulimia
nervosa and other eating disorders may
also be associated with perfectionism,
impulsivity, low self-esteem, and body
dissatisfaction.
Group Decreases Emotional,
Experiential and Relational
Avoidance
Emerging research points to the
central role of emotional and
experiential avoidance in the etiology
and maintenance of eating disorders
(Wildes, 2010). Most patients find
their symptoms adaptive and a useful
mechanism of self-control in the face
A PROFESSIONAL JOURNAL OF THE RENFREW CENTER FOUNDATION
of developmental change. Patients are
reluctant to relinquish symptoms that
have become an important source of
self-enhancement and emotion
regulation. Group therapy can therefore
be the perfect setting for patients who
are emotionally avoidant and anxious
about interpersonal closeness to safely
encounter difficult emotional experiences. Group therapy helps patients to
safely enter the uncomfortable and the
unknown.
Groups are likely to quickly produce
feelings in patients because of the
unpredictable range of emotional stimuli
and transference targets. Some of our
patients are approval seeking and fear,
as my teens say, “calling someone out.”
Disagreeing or having a differing view
is valued in the group by the leader as a
form of self-definition.We work on the
group norm and encourage individuals
to learn how to not hold back, and that
being too careful is a missed opportunity.
Patients will constantly say “I did not
want to say it because I would feel
uncomfortable or make others in the group
uncomfortable.” The group is trained that
we are interested in experiencing
unwanted negative feelings in the group.
If feelings in the group can be
experienced patients will become
more resilient, and more likely to
not turn to symptoms to avoid the
discomfort of these feelings.
Patients are reminded to try in group
to “say anything,” to be curious and
investigative about thoughts and
feelings and less judging.They are told
that whatever occurs to them in the
group, however small, may trigger
something helpful for someone else.
There is the constant attention to fears
and forms of resistance to using the
group. One long term group adolescent
anorexic patient said:
“Group helped me more than individual
therapy to open up and confront people
instead of keeping things in. I also used to
worry in the group that my issues were less
important and it was wrong to take up the
group’s time. I am much more open now in
group and I don’t feel guilty about talking or
taking up space.”
When dealing with group conflict
patients understand that personal attacks
are a violation of the group contract. If
it does happen, it is an opportunity for
feedback and seen as an unsuccessful
confrontation, and group learning or a
reality check.
The group is also encouraged to share
all of their conflicted feelings about
recovery and what is underlying the
symptoms that they fear giving up. I may
say“Mary needs to say everything she can
about feeling conflicted about getting better.
Maybe then she is less likely to go home after
group and binge and purge.” Members
are positively reinforced when they risk
expressing a negative feeling, especially
one directed at the leader.
One adult patient, recovering from
anorexia, began group five years ago
very reluctant and resistant. She was
quiet, “private,” isolated and conflict
avoidant. She had few intimate
relationships, and feared being
criticized. Group has been extremely
uncomfortable, especially when there is
a change in the group. Once a year she
questions how this discomfort is
helpful to her, and expresses her conflict
about leaving group. She has slowly let
go of eating disorder symptoms which
functioned as a substitute for intimate
relationships. She is socially confident
and has now opened her own successful
business.
Eating disorder patients also suffer
from body dissatisfaction and body
image distortion. One other essential
value of group therapy is having
individuals in various phases of treatment and self-development. Patients that
have begun to view their body image
more positively and accurately can help
other patients by giving feedback.The
range of perspectives helps patients to
reduce their body checking and
avoidance and to safely tune into and
explore their own distorted perceptions.
Group Elicits Patterns of
Self-Defeating Behaviors
When Sara reached her weight goal
the group began to call her Mom,
because she stepped in with advice
and care-taking. After a few weeks, she
described the difficulty of letting go of
the eating disorder and watching others
holding on. She confided that she
wanted to be the perfect recovered
patient and was beginning “to crack”
under the pressure. She wanted to leave
the group. However, her ability to
express feelings of envy and competition
mobilized other members to discuss the
same issue. She overcame her negative
PAGE 20
feelings and she once again engaged.
Self-defeating interpersonal behaviors
surface much more quickly in group
than in individual therapy. For example,
a socially anxious and needy patient
who does not stop talking demonstrates
her interpersonal difficulties immediately.
The group must avoid the trap of too
much interaction with this member
and should, instead, look to understand
the reason for the excessive talk, and
intervene. A solution might be for
the leader, as an example, to ask Mary
what she makes of Susan’s comment, in
order to interject another member and
promote interaction and group process.
The leader might say, “Everyone expresses
their difficulties in different ways, some have
to take the risk to listen more, some have to
talk more.” The leader can also point out
and ask about body language to get the
group talking. For example, “what is the
leg-shaking saying about what is
happening in the group?”
Group Helps Patients See How
Others Respond to Them and
Offer the Chance to Practice
New Behavior
Debra, an anorexic patient, joined a
long term group at the insistence of her
therapist who could not get her to talk
in individual therapy. Debra was terrified
of change and of any risk taking. She
had stayed at the same job for years
although she was overqualified and
bored. For the first five or six months
she said almost nothing in the group.
When pressed, she claimed to have no
insight, and that no thoughts occurred
to her. She was however progressing in
recovery and reached her weight goals.
What percolated was a vicious circle.
Anorexia had long been her main
relationship and accomplishment.
The fact that anorexia was moving into
remission meant others, who were
thinner and sicker, were getting more
attention.This added to her isolation, fed
her insecurities, and steeled her resolve
to silence.
Slowly the group nonverbally and
verbally expressed frustration with her.
They related their own discomfort
with opening up and claimed it was not
fair that she did not push herself.
Additionally, they said it was hard to feel
connected to her because she did not
share any of her thoughts and feelings
and that they knew nothing about her.
PERSPECTIVES • SUMMER 2012
As the leader, I too became frustrated
at her inability to express herself in the
group. In reflection I was experiencing
what Lawrence Epstein calls the “bad
analyst” feeling (Epstein, 1999), and was
internalizing Debra’s and the group’s
feelings of ineffectiveness and
helplessness.
Upon reflection, I went back to what
Anne Alonso (Alonso & Swiller, 1993)
calls “neutrality.” She said, “don’t just
do something, sit there.” This allows the
group to process and solve problems
without interruption. I realized my attempt to bring her out of silence was
not working, and that her interpersonal
task was simply to tolerate coming to
the group. Ironically she desperately
wanted human contact and feedback.
Her passivity was self-defeating and she
was pushing group members away. As
she began to talk she faced her fear of
change and criticism. Life outside group
slowly began to change as well. She went
back to school, changed jobs and slowly
began to make outside friendships.
Group also allows a patient to see
diverse responses to her behavior in the
spontaneous reactions from others. In
processing the group’s angry feelings
toward Debra, one patient suddenly became tearful. She identified with Debra’s
isolation and paralysis. Tracy shared:
“When I started group I only had room in
my head for thoughts about food and losing
weight. My only thought about the other
members was to compare my body to theirs.
Slowly, I came out of isolation and they
became real people that understood me.”
What about group therapists?
For therapists, conducting group therapy
presents a number of predictable
challenges. Many of these challenges
revolve around two main issues:
• How do you convince a patient that
the discomfort she may feel in group
will be helpful in her recovery, especially
when she is conflicted and ambivalent
about recovery?
• How do you engage patients in an
experience that is more compelling and
self satisfying than the symptoms that
give them self confidence, emotional
safety and a reliable sense of well-being?
Therapists treating eating disorders
understand that the best treatment
would be one that allows patients to feel
and experience the full range of conflicts
that have slowed the development of
the person and impaired their ability to
cope in life. Eating disorder symptoms
often leave little room for relationships.
Motivation and compliance in treatment
when behaviors and symptoms are egosyntonic is a common problem. Drop
out rates are high. Patients are resistant,
private, and shameful. Group therapy is
like asking them to walk the plank.
When patients team up or are angry
with the leader, it is an opportunity to
see how they work together and the
anger should not be taken away. It is a
chance for the leader to model something new by allowing for the safe
expression of negative feelings. From
an analytic perspective, it is the therapist’s job to metabolize and neutralize
negative projections. Patients can air the
negative transference anger, frustration,
and disappointments that they may avoid
expressing in other relationships. One
clear sign of countertransference is when
the therapist feels frustrated, ineffective,
deskilled, and devalued, as I did with
Debra above.We have to expect these
feelings and attempt to relinquish the
self-idealized therapist role and the need
to feel helpful and valued.The challenge
when inviting aggression is skilled and
measured responses, to use induced
aggression to contain the group without
acting out.
Group therapists also have to make
important choices about how they
handle group structure, consistency and
motivation.
Setting boundaries/rules and dealing
with “triggers.” If the group makes its
own contract, and is actively involved
in developing suggestions and
expectations regarding things like
attendance, contact outside of the group,
and the use of alcohol or drugs, there
is less potential for the therapist to be
perceived as arbitrary.While the general
principle of “say anything” applies, each
group must develop their own consensus about topics that could be “triggers,”
things that should not be explicitly
discussed in group sessions. Patients
may be offered the rationale that certain
descriptors may provoke competitive feelings or envy, and that negative
behaviors will follow. For example, talk
about food, weight or body image may
keep patients from getting to the deeper
issues underlying the eating disorder. I
have found it essential that these ‘norms’
PAGE 21
be developed by the group members
themselves, rather than imposed by the
group therapist.
I also find it useful to let patients air
their obsessions. Patients will call each
other on this and it is much more
effective for addressing how the
obsessions serve to avoid deeper feelings.
If the group drones on about food or
weight, we can investigate why and what
else is not being said. I may say:
Susan, are you following this? What do
you make of Nancy’s detailed description of
the evils of a French fry? I noticed 3 people
got up to use the bathroom and three sets of
legs are shaking? Does anyone have a theory?
Maintaining motivation and
challenging “stuckness.” The best
approach when encountering lack of
motivation or resistance is to invite the
group to do the work and resolve them.
The therapist might say, “How are we as
a group failing to help Kate?” I also may
engage a member that had a past shared
resistance, for example, “Nicole, you were
silent in group for a long time. How did the
group help you?” Motivation is mobilized
when patients feel a presence and a sense
of importance in their role in the group.
When members see changes or a more
flexible mode of interpersonal interaction
in others they will comment reinforcing
individual and group progress.
We want members to show their
individual resistances to change and to
show us what they do in the real world.
Our compliant eating disorder patients
will sometimes be cooperative and
desirable concealing other feelings and
behaviors. Good behavior that is free of
conflict gives us less to work with.The
therapist needs to identify individual
resistances that, unexpressed, become
destructive to the group. New
members coming into the group, or
those terminating, stir up feelings.
Patients often leave group when these
conflicts, resistances and fears are not
explored and when patients
cannot express negative feelings about
the group or the group leader.
Integrating treatment approaches
I have recently started to integrate
a skills building component to my
group therapy program. Inserting DBT
practices into group has been positive
for most patients, however some have
remarked that they find the didactic
A PROFESSIONAL JOURNAL OF THE RENFREW CENTER FOUNDATION
nature of the skills training uninteresting.
Patients find education about the skills
helpful during a designated time in the
same way cognitive behavioral goal
setting is planned for the beginning or
the end of the group.They sometimes
find it helpful to practice the skills in
the moment or spontaneously try to
identify what skill is being used by a
particular member. Some have been
vocal about the structured nature of the
skills training interrupting a need to
talk about something else or follow up
on unfinished business from a previous
group. Adolescents have reported that it
is boring.The effective group therapist
needs to balance efficient use of time
and effort in skill development with the
vital learning dimensions of the here and
now. I have found it important when
using CBT, homework goal setting, and
DBT skills training to check in with
patients regarding their reactions.They
will guide me as to how best to use, and
how much time to spend on, structured
exercises. Ideally, a skills group would be
more separate than an integrative process
group but that can be logistically
difficult in private practice.
SUMMARY
Group therapy is a cost effective
treatment that allows for self-expression
and the consequent building of
competence and confidence. It is not
just support but treatment of the
isolation of eating disorder illness.The in
vivo practice of new skills while facing
unwanted emotional discomfort, and
unpredictability produces maturation
and resilience. It is an opportunity to
rehearse for the world. Patients practice
self-expression and assertion in giving
and receiving feedback. I train my group
patients that the discomfort of risk
taking will help them to become
emotionally resilient and less dependent
on their symptoms to cope with stress.
We learn quickly about the way our
patients behave in their interpersonal
world, including issues and behaviors
that may not come out or are slow
to surface in individual therapy. More
witnesses and reaction to the salient
self expressions made in group leave a
deeper imprint in one’s mind.What our
patients experience outside of group
inevitably emerges inside the group as
well. As these patterns emerge, they can
be resolved in the moment.
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Agras,W. S.,Telch, C. F., Arnow, B.,
Eldredge, K., & Marnell, M. (1997). One
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Clinical Psychology, 65, 343-347.
Alonso, A., & Swiller, H. (1993). Group
therapy in clinical practice.Washington,
DC: American Psychiatric Press, Inc.
Arnow, B., Kenardy, J.,& Agras,W. S.
(1992). Binge eating among the obese.
A descriptive study. Journal of
Behavioral Medicine, 15, 155-170.
Epstein, L. (1999).The analyst’s “bad
analyst feelings”: A counterpart to the
process of resolving implosive defensives.
Contemporary Psychoanalysis, 35, 311-325.
Fairburn, C. G., (1995). Overcoming
binge eating. New York: Guilford Press.
Klerman, G. L., & Weissman, M. M.
(Eds.) (1993). New applications of
interpersonal therapy.Washington DC:
American Psychiatric Press.
Kohut, H. (1984). How Does Analysis
Cure? Chicago: University of Chicago
Press.
Linehan, M. M., & Chen, E.Y. (2005).
Dialectical behavior therapy for eating
disorders. In A Freeman (Ed.),
Encyclopedia of cognitive behavior
therapy (168-171). New York: Springer.
Schwartzman, G:The use of the group
as a self-object. Int J Group Psychotherapy
34: 229-241, 1984.
Strober, M. (1991). Disorders of the
self in anorexia nervosa: An organismic
developmental paradigm. In C. Johnson
(Ed.) Psychodynamic treatment of
anorexia nervosa and bulimia. New York
NY: Guilford Press.
Strober, M., & Goldenberg, I. (1981).
Ego boundary disturbance in juvenile
PAGE 22
anorexia nervosa. Journal of Clinical
Psychology, 37, 433-438.
Spotnitz, H. (2004). Modern
psychoanalysis of the schizophrenic
Patient.YBK Publishers.
Tasca, GA., Ritchie, K., Conrad, G.,
Balfour, L, Gayton, Daigle,V., & Bissada,
H. (2006). Attachment scales predict
outcome in randomized controlled trial
of two group therapies for binge eating
disorder: An aptitude by treatment
interaction. Psychotherapy Research, 16,
106-121.
Wilfley, D. E.,Welch, R. R., Stein, R.I.,
Spurrelli, E. B., Cohen, L. R., Saelens,
B. E., et al (2002). A randomized
comparison of group cognitivebehavioral therapy and interpersonal
therapy for the treatment of overweight
individuals with binge eating disorder.
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Wildes, J. (2010). Emotion Acceptance
Behavior Therapy: A new treatment for
older adolescents and adults with
anorexia nervosa. Perspectives, Winter,
2010.
Wisniewski, L. & Kelly, (2003).The
application of dialectical behavior
therapy to the treatment of eating
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Wonderlich (2002). Personality and
eating disorders. In C.G. Fairburn &
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Guilford Press.
Cindy James, Ph.D.
started as a group clinician
in psychiatric nursing at
UCLA Neuropsychiatric
Institute and Hospital 30
years ago. She was an
assistant clinical professor
and co-directed the outpatient eating disorder program at UCLA
before moving to Connecticut. She has been
in consultation with Dr. Lawrence Epstein
learning the modern analytic approach in
facilitating group therapy for the past 15 years.
She is currently in private practice in Westport,
Connecticut.
PERSPECTIVES • SUMMER 2012
The Renfrew Center’s Newly Designed Website
PAGE 23
The
www.renfrewcenter.com
Renfrew Center
Foundation
will offer
professional seminars
and webinars
throughout the fall.
This new website combines the former Renfrew Center and Renfrew Center Foundation
websites so everything is in one place. On the website you will discover an easy to
navigate layout, new images, upcoming Renfrew events, and much, much more.
Please visit
www.renfrewcenter.com
If you click the For Professionals section, on the left side of the home page, you will find:
•
•
•
•
•
A step-by-step guide of our referral process
A variety of materials to help educate your clients and enrich your practice
Testimonials from fellow professionals
Programs provided by The Renfrew Center Foundation throughout the year to help
enhance your experience
Current job opportunities at The Renfrew Center
A
for information
on these events.
Your Donation Makes a Difference
s a professional and educator working with individuals
affected by eating disorders, you are undoubtedly aware of the
devastation these illnesses cause to families and communities.
The Renfrew Center Foundation continues to fulfill our mission of
advancing the education, prevention, research and treatment of eating
disorders; however, we cannot do this without your support. Your Donation Makes A Difference…
• To many women who cannot afford adequate treatment. • To thousands of professionals who take part in our
nationwide seminars and trainings. • To the multitude of people who learn about the signs and
symptoms of eating disorders, while learning healthy ways
to view their bodies and food. • To the field of eating disorders through researching best
practices to help people recover and sustain recovery. Please designate below where you would like
to allocate your donation:
q Treatment Scholarships
q Training & Education
q Area of Greatest Need q Research
q Barbara M. Greenspan Memorial Fund
Name _________________________________________________
Address ________________________________________________
City/State/ZIP__________________________________________
Phone/Email ___________________________________________
Below is my credit card information authorizing payment
to be charged to my account.
An important source of our funding comes from professionals like
you. Please consider a contribution that makes a difference!
Credit Card # ___________________________________________
Tax-deductible contributions can be sent to:
The Renfrew Center Foundation
Attn: Debbie Lucker
475 Spring Lane, Philadelphia, PA 19128
Credit Card Type _________________________________________
Security Code ________________ Exp. Date __________________
Amount Charged _________________________________________
Signature/Date ___________________________________________
NON-PROFIT ORG
U.S. POSTAGE
PAID
THE RENFREW
CENTER FOUNDATION
The Renfrew Center Foundation
475 Spring Lane
Philadelphia, PA 19128
1-877-367-3383
www.renfrew.org
The opinions published in Perspectives do not necessarily reflect those of The Renfrew Center. Each author is entitled to his or
her own opinion, and the purpose of Perspectives is to give him/her a forum in which to voice it.
L O C A T I O N S
1-800-RENFREW
www.renfrewcenter.com
Northeast Sites
Philadelphia, Pennsylvania
475 Spring Lane
Philadelphia, PA 19128
Radnor, Pennsylvania
320 King of Prussia Road
2nd Floor
Radnor, PA 19087
New York, New York
11 East 36th Street
2nd Floor
New York, NY 10016
Southeast Sites
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15000 Midlantic Drive
Suite 101
Mount Laurel, NJ 08054
Ridgewood, New Jersey
174 Union Street
Ridgewood, NJ 07450
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Charlotte, North Carolina
6633 Fairview Road
Charlotte, NC 28210
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