Working Through Groups: An Experience of Nutrition and Eating Disorders Services
Premise
Within the Italian public NHS and more specifically within the Department of Mental Health and Pathological Addictions are located the Services for Nutrition and Eating Disorders. These pathologies in recent years, and especially following the Covid 19 Pandemic, have had a significant increase. The Territorial Services are organized with Specialist Outpatient Clinics that deal with the 12-60 age group and are located within the network of different levels of care indicated by the Italian Ministry of Health.1
The Service has been in operation for more than twenty years and is also connected to a Regional Network of other Services, which aims to keep the Guidelines up to date and to provide guidance on the Organization of the Services’ working methods, also with reference to the increasing complexity of patients.
The transversal elective working method is that of the multidisciplinary approach that extends to the 5 Levels of Care. Each level includes several disciplines: Psychology, Individual and Group Psychotherapy, Child Neuropsychiatry/Psychiatry, Internal Medicine, Dietetics, Psychiatric Rehabilitation Technology, and Family Psychotherapy. Other medical specialists may be added as needed in relation to the problems encountered. The Service also collaborates with other Medical professionals, Social Service and Schools, depending on the needs of the case.
Patients are referred by General Practitioners or Primary Care Pediatricians, school teachers, family members/friends. Sometimes the access is spontaneous. In case of minors, it is required that they are always accompanied by their parents.
After the Intake phase, if the referral is considered appropriate, an initial visit and a multi-professional assessment phase lasting 2-3 meetings is conducted. Within it, for the psychological part, psychodiagnostic tests are administered, clinical interviews are conducted, while for the medical-nutritional part, objective examination, evaluation of laboratory tests as well as a compilation of the nutritional plan followed up to that moment are carried out. Within the multi-professional assessment meeting, there is a discussion with the patient and family about what has emerged both from the psychological and the medical-nutritional point of view; if the patient decides to adhere to the treatment plan, the overall team evaluates the most appropriate intervention to be put in place and the level of care from which to start.
Over time, the Service has identified the group work modality as an effective working tool, using it in a variety of clinical problems.
In this article we will discuss psycho-educational groups for family members according to the New Maudsley Model method, time-limited psychotherapeutic groups, psycho-educational groups for Patients Suffering from Binge Eating Eating (BED), and rehabilitative psycho-educational groups.
Working with families according to the New Maudsley Model
Since 2018, at the DNA Outpatient Centres of the AUSL-IRCCS of Reggio Emilia and other AUSLs in the Emilia Romagna Region, the New Maudsley Model method has been introduced with the aim of taking care of family members of patients with DNA.
Living with these diseases can have a significant impact on the psycho-physical balance of each family member. Family members generally feel poorly “equipped” in coping with the disease and weak in regulating emotions. The expressed emotionality, correlated with both the severity and duration of illness, produces an overprotective response towards ill family members, comparable to that developed by many other organic diseases.
Our services have always offered families the opportunity for family counselling or psychotherapy pathways involving all members of the family unit.
The New Maudsley Method, however, as devised by psychiatrist Janet Treasure and associates2, has enriched the range of clinical offerings and introduced new approaches towards family involvement, especially regarding patient’s healing process.
This method aims to identify relational dynamics that can maintain illness, visually represented with animal metaphors related to commonplace, on which therapy work can focus.
The animal metaphors of dynamics that would not facilitate change are: ostrich, fox terrier, jellyfish, rhinoceros and kangaroo; in contrast, the most desirable ones are St. Bernard’s dog and dolphin, which aim at empathy, understanding, dialogue and overcoming difficulties and fears
The action of mirroring, empathy, and the collaborative attitude that helps in overcoming guilt allow family members to get broader perspective on the illness and allows the therapist an implemented transdiagnostic observation.
Confrontation between professionals, family members, and patients produces constant and ongoing discussion about the goal of the treatment pathway, hence the possibility of change. Moreover, it is essential to create a supportive environment and an emotional atmosphere that stimulates and facilitates this change, according to a transtheoretical model that provides five stages of “readiness”: unthinkable, the patient is not yet ready to consider change and is in the Honeymoon stage with the symptoms (a term coined by Lacan when defining the illness stages of patients with pathological dependence); thinkable, he is ready to think about change; in preparation, he plans changes but does not implement them; action, he enacts change; maintenance, change becomes habitual.
The basic training consists of 8 meetings: an initial foundational one, allows patients and presenters to get to know each other, the 6 central meetings cover differents topics, while the final one is dedicated to concluding considerations and greetings. In the last meeting the participants are introduced to “Crumbs” Volunteer Association, composed of family members of former patients who attended the Service Care, who play a supportive role in this treatment pathway. Role playing, exercises and representations of lived realities complete the experiential framework and give the opportunity to experience themselves directly, while remaining in a protected environment. At the end of the psycho-educational course, a final follow-up meeting is scheduled after about a month, to evaluate the progress of the acquired skills.
Before the arrival of the COVID 19 pandemic, there used to be an advanced group, subsequent to the basic group, joined by experienced parents who participated along with other parents, who where still experimenting and confronting the New Maudsley Model Method before stabilizing the learnings. Such a group allowed those who encountered difficulties in changing their emotional register with their family members to exercise, while remaining in a protected setting. It was an important group, momentarily stopped during the Pandemic, that will be reactivated in the upcoming months thanks to volunteers cooperation.
Considering the social isolation rate experienced by patients and their families, psycho-educational groups designed in this way appear to be a valuable aid in reformulating an informal, non-judgmental network of relationships where the participants can experiment, possibly make mistakes and learn from their own mistakes also through the help of other people.
While the psycho-educational groups in the early years were held in-person only, during the Pandemic it became necessary to revise the way the groups were conducted, in particular by using of telematic support. Adaptation of the model to the new communication channel allowed for greater continuity in the work of reflection with family members and support in the patient’s care pathway, containing lockdown damage, ensuring a specialized help during a traumatic time for the entire population.
The results collected through a multicenter study within the Region’s DNA programs, which will cover the time frame from 2019 to 2023, will be announced later.
Time-limited psychotherapeutic group
Time-limited group psychotherapy is one of the interventions proposed. It offers particular advantages in therapy such as the dilution of the intensity of the transference relationship, an opportunity for multiple identifications and reception of feedback from one’s peers, a greater orientation to reality based on the real interactions that are activated in the group itself 3.
The isolation of patients suffering from eating disorders hides a deep fear of confrontation with the Other, feelings of insecurity and worthlessness. The group gets in touch with these fears, prompts them to be expressed and experienced until they can slowly be circumscribed and resized. The personal resonances provoked by group interactions often bring out experiences that have not yet been processed and activate latent intrapsychic dynamics, which many times have not yet found a way of expression in individual therapy. Individual exposure to an expanded relational context has repeatedly proven useful not only to overcome the inevitable moments of stasis that occur during individual psychotherapies, but also to bring to light, although in a non-painful way, pseudo-psychic balances that are considered functional and established4.
Being in the group exposes us to the judgment of the Other, allows us to integrate others perceptions of us into our own selves and to become aware of the parts of us that we place in relationship with the Other: sharing, the possibility of identification, and the recognition of differences in the group facilitate the change of the rigid and static image that patients have of themselves and allow them to experience different ways of representing themselves and relating to others5.
Patients are selected with a criterion of homogeneity by diagnosis, age group, compensation on the organic level, therapeutic goals and motivation to participate in a group.
Homogeneity by diagnosis has the initial advantage of promoting faster cohesion and interaction in the group6.Patients, trough the sharing of similar problems and finding aspects in common, have an easier time getting involved and identifying resistances and mutual ambivalences.
The goals are to help patients modify their relationship with the eating symptom, promote an increase in coping skills, in interpersonal and emotional functioning and improve the quality of social and family relationships7.
The group is done weekly, consisting of 20 sessions lasting 90 minutes. It is led by a group conductor, who takes an active, structuring position from the beginning of group formation. He involves members in interaction, sets boundaries, stimulates the identification of each person’s characteristics that are different from those of others and that characterize the individual. The group conductor also leads back and maintains interaction to the central goals of the group path. The conductor’s attention always remains focused on the group’s interaction and process, encourages individuals to take responsibility for themselves and for their feelings and behaviors, helps them recognize changes and what hinders change.
Those who enter the group, after a few meetings, come into contact with a great deal of experiences, emotions, different points of view, suffering and problems related to the eating disorder, brought by the other patients present. This leads the patient to perceive more and more the complexity related to his situation and to consider his own personal resources insufficient to cope with it. All this, through the support of the participants and to a facilitation aimed at mobilizing every resource in the group, leads the patient to recognize with greater conviction his or her need for help (this aspect is very often difficult for these patients to accept as they are very focused on being “performing and autonomous”), to improve compliance with the health professionals involved in the multidisciplinary treatment, and to produce greater readiness for personal change.
Psycho-educational group for patients with Binge Eating Disorder (BED)
Binge Eating Disorder (BED) is a disorder characterized by the presence of “binges” unaccompanied by strategies to compensate for excessive food ingestion. Uncontrolled eating disorder is related to obesity although this characteristic is not necessary for the diagnosis of BED.
A problematic psychological structure characterized by depression, body dissatisfaction, and variously disturbed eating behavior is common in BED individuals. Mood disorders and other psychopathological pictures seem to be present in about 80% of cases.
The therapeutic process is long and characterized by strong ambivalence. The BED subject on one hand would like to shed his armor, on the other hand he regularly boycotts any progress.
Fear is the patient’s chronic condition. Fear of not measuring up, of being inadequate, of being abandoned, rejected.
They often seek each other’s approval; if it does not come, they have bouts of bitterness and despair that leads them to binge craving. Their ability to tolerate frustration is very low.
At the Reggio Emilia DNA Center, a therapeutic psycho-educational group path, specifically for BED, has been devised.
People who present with the diagnostic criteria for BED are included in the group; the group is time-limited and sessions are weekly of one and a half hours for a cycle of 8 sessions, plus a follow-up meeting one month after termination. The group is co-led by a psychologist and a psychiatric rehabilitation technician.
The goals of the group: increasing awareness of the sequentiality of the patterns one adopts, understanding the function of binge eating, managing emotions and improving lifestyle.
The first sessions are devoted to identifying binge triggers, function and possible alternative activities; the remainder to managing emotions, knowing how to recognize and code them in the right way, increasing the patient’s awareness of the sequentiality of the patterns he adopts, and hints of mindful eating.
During the last meeting, a review of the course taken is made, and the same at the follow-up meeting. During this follow up meeting the aim is also to identify any other treatment paths to be taken as new needs emerge.
New rehabilitation proposals: telematic “emotion group” and “relaxation group”
The “emotion group” and “relaxation group” are open groups and follow the “in and out” flow of the users in charge in the Day Service-assisted meals pathway. The decision to structure the groups with flexible entry, was motivated by the continuous flow of entries with different timings and are organized in such a way as to allow a turn-over of users, limiting the repetition of the topics covered. In this regard, to facilitate sharing and interaction among participants, an icebreaker game selected in advance by the presenter is provided at the beginning of each meeting of both groups.
Phobias in relation to feeding are usually secondary events, that is, they follow a normal feeding period for the developmental stage. Clear triggers may be traumatic events for the child. Food phobia may be a feature of a more pervasive anxiety disorder or obsessive-compulsive disorder. In many cases, it is not the symptomatology of the eating disorder per se that leads the child or adolescent with the eating disorder to treatment, but rather the presence of a serious comorbid problem or condition that requires medical and/or psychiatric counselling, for example, a state of depression and/or anxiety. Even when the eating disorder is diagnosed from the outset, the identification of any comorbid anxiety and/or depressive symptoms in developmental patients is of utmost importance for treatment outcome. Psychiatric comorbidity is an extremely frequent clinical feature in individuals with extreme dieting behaviors: 62% of such individuals report high levels of both anxiety and depression. Fear is the emotional response to an imminent threat, real or perceived, while anxiety is the anticipation of a future threat. These two states overlap, but they are also different: fear is more often associated with spikes in autonomic activation necessary for fight or flight and thoughts of immediate danger, while anxiety is more frequently associated with muscle tension and vigilance in preparation for future danger and cautious or avoidance behavior. Sometimes the level of fear or anxiety is reduced by pervasive avoidance behaviours. For this reason, it is essential to include relaxation training that can aid patients in managing the specific phobia related to meal intake and more generally to times of the day when they experience high levels of anxiety.
The “relaxation group” is held on a weekly basis with a duration of 90 minutes per meeting. It specifically addresses psycho-education and anxiety literacy, which promotes the acquisition of awareness of associated physical manifestations and the ability to discern from the concept of fear. This is supported by an explanation of the “anxiety hill” that helps participants understand the physiology of anxiety states; indeed, it is often reassuring to normalize such physiological manifestations as events that have a beginning and an end. The concepts brought up during the meetings focus on the importance of changing the perspective of the physical self, referring to the ability to carve out one’s own moment, to perceive and reflect on the body not as a physical body but as a dialoguing body that sends signals about our state of well-being and/or muscle tension. During the meetings we focus on breath meditation, isometric relaxation techniques and training the ability to focus attention, bringing thoughts back to the present moment. The type of patients afferent to the course made it necessary to focus on terms such as “muscle groups” and the exclusion of certain areas of the body, to avoid excessive focus on strictly physical aspects. The experience gained in conducting the various relaxation group cycles highlights the difficulty of some participants in abandoning hyper-control over the tensions of their bodies and allowing themselves the static nature of the encounter; these are dissonant elements typical of eating disorders. Such difficulties are returned to users as useful resources and tools for working on self-awareness and understanding the mechanisms of action of the disease. It also allows users to apply the techniques experienced in the group, even at specific moments such as assisted mealtimes.
The “emotion group” is essential for the type of users who present one or more difficulties in managing emotions, meaning by this definition both the tendency to perceive emotional states as too intense and inappropriate and the feeling of not perceiving them at all (alexithymia). Addressing excessive self-control of emotions and behaviors can be important, as poor awareness of emotions and cognitive inflexibility can be obstacles to recovery in anorexia nervosa8. Providing the opportunity to experience emotions allows people to perceive them as a source of information about their emotional states and relationship with others rather than stopping at the dichotomy between “positive” and “negative” emotions, which necessarily results in a tendency to censor some of them.
The “emotions group” is held on a weekly basis with a duration of 90 minutes per meeting. The topics covered during the meetings deal with psycho-education and basic emotion literacy. Psycho-educational intervention is aimed at activating a process of learning, strengthening and generalization of emotional regulation skills. Emotional literacy is aimed at the identification and description of emotions (including from the perspective of physiological correlates, facial and postural expressions) and their function in terms of indicators of internal states and means of interpersonal communication. A number of fact sheets (“wheel of emotions” and “charter of rights to emotions”) are shown during the meetings, useful for introducing basic concepts, which are repeated throughout the meeting cycle. Another proposed topic concerns the introduction of the “ABC method” and “mind viruses” useful for exploring thoughts and emotions. Ellis proposes the ABC method9, which consists of identifying A, which is a problem situation, B, which consists of the thoughts that emerged in that situation, and C, which corresponds to the emotions felt and behaviors enacted in response. With this technique, the relationship that exists between B and C is inferred, as it is precisely thoughts that generate emotions and, therefore, by modifying them, emotions are modified. This basic concept introduces the work related to so-called “mental viruses”; these are cognitive biases that are often activated automatically but to which it is important to pay attention and recognize them in one’s inner dialogue. The mental viruses most often encountered are the following: expecting and demanding (i.e., thinking that things must necessarily be done that way or that others must behave according to rigid rules that we impose on ourselves); giving wrong interpretations (i.e., giving incorrect explanations about something that has happened e.g., blaming ourselves for something without any basis for it or believing that the other person has behaved badly toward us just to wrong us), devaluing (i.e., judging someone in a completely negative way because he or she has done something wrong or unpleasant), magnifying (i.e., magnifying the negative aspects of what is happening or could happen), and generalizing (i.e., using extreme and general expressions such as “never, always, no one or everyone,” without being able to substantiate the events).The experience gained in conducting the various “emotion group” cycles highlights the tendency to share emotional states with other users, to discover different ways of interpreting and expressing emotions. Finally, it is observed that the high degree of dynamic interaction allows decentralization from thoughts of illness.
Activation and inclusion in rehabilitation groups increase patient’s perception of belonging to a group with which they ideally share the difficulties of the treatment path and more generally of the disease.
Conclusions
This article discusses the different ways of using the group in the treatment path of Nutrition and Eating Disorders. The group work tool adapts well to different clinical needs. Time-limited Homogeneous Psychotherapeutic Groups offer a valuable opportunity for people, who experience strong feelings of shame and guilt, to feel not judged but understood in their difficulties, stimulating self- individuation. Psycho-educational groups for family members according to the New Maudsley Model have proven to be very useful in helping family members understand the dynamics that are likely to set in and that privilege the illness instead of fighting it. Psycho-educational groups for BED patients help them understand what situations trigger the symptom and identify new relational and communication strategies. Rehabilitation groups support and broaden patients’ experiences through confrontation, providing a reflection on the mental stages of distress and developing real inner dialogue.
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Gibin A.M*, Ghidoni A.*, D’Acquisto F**, Boiardi F.***
*Group-analyst and individual psychotherapist ** Psychiatric Rehabilitation Technique ***Psychiatry resident doctor – Reggio Emilia AUSL IRCSS (Italy)