Topic 9: CBT Groups for Eating Disorders & PTSD {by 11/19}

There are two readings due this week – Bieling et al. Chapter 12 and Jones (2007).  Address the following two discussion points: (1) Is CBT effective for treating eating disorders (focus on Anorexia Nervosa and Bulimia Nervosa)? Explain your response within the context of group therapy. (2) CBT treatment for PTSD has many variations. Yet, the majority of them have similar cognitive and exposure mechanisms for working on the trauma. How can group exposure techniques for PTSD be effective considering the nature of varying traumatic experiences? Your original post should be posted by the beginning of class 11/19.  Have your two replies no later than 11/21.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

20 Comments (+add yours?)

  1. Gil
    Nov 16, 2014 @ 13:32:31

    As I was reading the chapter, I kept seeing connections between eating disorders and substance abuse. First, addressing motivation seems like an essential first step before change techniques can be best used. CBT techniques are more effective when the individual’s motivation to change is sufficient. There are high risk situation and stimuli that will trigger their problematic behavior. Underlying their problematic behavior are other issues that they are often trying to cope with including problematic emotions and a negative self-view. Although CBT is probably the first treatment for eating disorders, the effectiveness for treating eating disorders does not mirror the success for CBT in treating other disorders like depression and anxiety. One study showed that CBT was 50% effective in its treatment of individuals with bulimia nervosa. A coin flip, ignoring relapse, is not the pinnacle of psychological treatment. Anorexia nervosa is more resistant than BN and has mixed effectiveness rates with CBT treatment. Moreover, like with substance abuse, relapse is somewhat expected. Additionally, both disorders have a high comorbidity rate that make research on the subject less clear in its generalizability. The unpleasant effects of discontinuing substance use is mirrored by the unpleasant effects of reintroducing normalized eating. Treatment of the disorders also runs up against the “current” of society. Just as drinking is socially acceptable and interwoven in many social events, talk of dieting and having an idealized body is on the shelves of every checkout line.

    Ultimately, there are overarching principles that guide the treatment of PTSD. The trauma may be different, but the effects of the trauma often follow a pattern. Altering distorted beliefs about their assumptions about the meaning of the trauma or their perception of self can be applied to various traumas. The trauma may be a source of guilt and the individual must process these feelings and reappraise their culpability. The individual may feel less in control of their situation and must go through experiences that reintroduce their sense of either control or acceptance of dyscontrol. These cognitive aspects of PTSD are used to develop exposures to introduce or reinforce these changes. The exposure serves to have the individual face their feared situation and process the situation, but in a safe and controlled manner. The danger of the situation can be reevaluated as the person no longer uses avoidance as their method of coping. Each member can face their own trauma and begin to habituate to their conditioned anxiety.


    • Angela Vizzo
      Nov 17, 2014 @ 22:07:48

      Gil, I really like your discussion of how treating eating disorders and treating substance abuse are similar. I have to agree, both are addictions, one to a substance and another to a behavior, and as such have similar characteristics. As you pointed out, one of those characteristics is motivation to change which is very important to treatment, especially CBT as so much hinges on the individual’s behavior and the willingness to change that behavior as well as the way they think.


      • Richard Hisman
        Nov 19, 2014 @ 08:43:24

        I actually immediately thought of the anger groups for adolescents and how the group could easily begin to reinforce each others dysfunctional behaviors. Or how individuals how are self-harming may compare techniques. The therapists woulld have to be on top of the game when it comes to monitoring this group. Unlike substance abuse,where there is chemical addiction in most cases, eating disorders are behaviorally addictive. There is no initial drying out or detoxing component to deal with. One simple step to substance use is changing the enviroment, an often overlooked component of recovery. In eating disorders, simply changing friends, places and things would not help to the same extent.


  2. Sarah-Eve
    Nov 16, 2014 @ 17:06:02

    CBT for eating disorders emphasizes the development and continuation of maladaptive eating patterns. Extreme attitudes about weight, body shape and size, and beliefs about the self may attribute to eating disorders. According to the literature, CBT has been shown to be more effective in reducing symptoms associated with Bulimia Nervosa (BN) and Binge Eating Disorder (BED), than Anorexia Nervosa (AN). CBT has shown to be helpful in treating AN, but has not shown as much promise as it has with other eating disorders. Group CBT techniques have had similar results in that it shows more promise for BN than AN. There are many possible reasons for this. For example, in BN, binging and purging is not a necessarily pleasant coping strategy. Stopping an unpleasant experience in BN is different than starting an unpleasant experience (eating for someone diagnosed with AN). For someone who suffers from anorexia, the process of re-feeding is not necessarily a pleasant one. Many side effects (e.g., stomach aches, etc.) may slow down the process of re-feeding. For someone with BN, binging and purging may cause one to feel out of control (a negative emotion), while restricting promotes feelings of control (a positive emotion). For these, and many other reasons, AN tends to be a more pervasive and long lasting disorder than BN and is more resistant to treatment, group or individual. While purging has more negative side effects (e.g., weight gain, not socially acceptable), individuals who restrict often receive plenty of positive reinforcement in the early stages of weight loss.

    Group exposure techniques for PTSD can be effective considering the nature of individual’s traumatic experiences. Empirical studies suggest that individuals explore the trauma directly in a safe way in order to restructure responses that have become ineffective in daily life. Including relaxation, stress management techniques, and desensitization during exposures can help reduce PTSD symptoms. Group therapy allows individuals to learn from each other and be more willing to try reframing situations when others have successfully done so. Exposures to traumatic situations (done so in a safe environment) can help address cognitive distortions that are strengthened by the original trauma and the avoidance of situations perceived as similar. Done in a group setting, individuals experiencing exposure may receive support from other group members. The presence of group members may also enhance the feeling of safety and self-efficacy in an exposure setting.


    • Sarah Gagne
      Nov 21, 2014 @ 21:43:06

      I like how you mention that the weight loss associated with AN is positively reinforced initially. It seems that eating disorders are valued in certain populations due to the outcomes and this does not seem to be the case in many other psychiatric disorders. This makes CBT very difficult to implement; why would someone be motivated to change if they are positively reinforced or can be successful, such as in modeling or athletics?


  3. Angela Vizzo
    Nov 17, 2014 @ 22:11:30

    I like your discussion of treating PTSD in a group setting. You did a nice job covering all major components and the advantage of the safe environment that group therapy can provide. In addition, the normalization of trauma responses can be provided in group treatment more effectively than individual, which can be an important component especially for children and adolescents.


  4. Angela Vizzo
    Nov 17, 2014 @ 22:30:52

    CBT for treating eating disorders has been found to be effective, in general. For treating BN, CBT is a first line treatment and it shows efficacy, though it is important to note that the degree of symptom improvement is limited with only 50% of patients displaying symptom remission. In treating AN, results are preliminary, as the disorder is understudied, but they do show promise. In regards to treatment in groups versus individually, results are mixed with some studies showing equal efficacy while others show poorer outcomes for group treatment. One major component of treatment for eating disorders that CBT can lack is the family component, which is important to be addressed as the family environment plays a large role in the development and maintenance of the disorders.

    Group exposure for PTSD can be effective in group treatment, despite different traumas of each member, as it takes the form of a trauma narrative. During this exercise each individual reads an account of their traumatic experience. Other members are encouraged to normalize the traumatic responses and identify misattributions/distortions within the narrative. In addition, members practice in vivo exposure as homework and when reviewing this as a group the leader points out aspects of the experience that can be generalized to the whole group.


    • Sarah-Eve
      Nov 18, 2014 @ 10:15:13

      Angela, I really liked that you mentioned a lacking family component to CBT for Eating Disorders. For adolescents and younger, the Maudsley Approach is the most empirically supported treatment to date. It is a family approach that incorporates parents and other members to take part in treatment (both with individual case management and in family oriented groups). There are many positives to this type of treatment as it addresses issues within the family unit and not solely within the child. Unfortunately, there are also many downsides to this approach. For example, it puts parents in full control of the child’s recovery. They make the meals, etc. which really limits the amount of a learning a child can do if they are not participating in these processes as well. This approach is also much more difficult to implement in older individuals. Though family meetings are always encouraged (at least in the program where I am interning they are), it is not always possible to get the whole family in or the client may refuse these types of meetings.


    • Gil
      Nov 18, 2014 @ 10:27:23

      You make a good point about incorporating the family into treatment. A individual with an eating disorder may not be able to restructure their environment. Many younger people have eating disorders and already have a lack of control over their situation. Family therapy gives the therapist a chance to witness the possible maintaining aspects of the family and work to have the family be supportive of change


  5. Richard Hisman
    Nov 18, 2014 @ 10:03:00

    There are really two separate situations, one being PTSD in youths and the other PTSD in adults. First we will deal with a youth and then adult situation. The youth really draws in the additional complication of limited life experiences. There is a much smaller sample of successful experiences that can be used to balance any traumatic event. This can add to the avoidance behaviors strength by seeing any situation that invokes the memory of the traumatic event as being equal to that event. In other words, the overgeneralization of similar events is magnified through lack of experience. In the adult it is a much more conditioned behavior, in which fear and the resulting avoidance becomes reinforced. This then leads to the similar overgeneralization of the event(s).
    The group setting is key in one respect as it is in other dysfunctional behaviors in that everyone in the group has avoidance behaviors. They are not alone and group may be the first time they associate this. The group supplies likeminded individual’s mutual support while exploring alternatives to their avoidance behaviors. Working through cognitive distortions takes on a more relevant course of action through the support of the group. In other words false negative thoughts or beliefs can be successfully worked through as a group avoiding getting caught up at individual stuck points. Witnessing each other work through exposure training is a powerful tool. Actually seeing one get caught up in a distortion and overgeneralizing it makes the others aware of these stuck points.
    While evidence suggest that group CBT for BN and BED can be effective, there is not much support for group CBT for AN. The groups run for a longer period than most CBT group, typically 18 – 20 weeks. A problem with treating BED and BN is that a period of ambivalence can occur where the client may not progress. While group therapy has increased the individual involvement in engaging in one’s treatment, there is also those whom increased their avoidance behaviors negating treatment. Like anger, the group can reinforce or develop new avoidance techniques through comparison of each’s behaviors. It is definitely a group that would take special skill sets to manage. One would need to be prepared for any challenges presented by the clients and be able to get them to stay involved at a personal level.


    • Sarah-Eve
      Nov 18, 2014 @ 10:24:54

      Pointing out that age can have an effect on the way PTSD symptoms are reinforced within an individual is important. Especially when I child has less experiences to compare their trauma to, without treatment in close proximity to the trauma, these negative behaviors or avoidance techniques may become much more difficult to extinguish. Using group techniques to magnify the positive effects of going against the avoidance behaviors through exposures can be effective. When others see that these techniques have worked for their group members, they may be more willing to try it. The safety of the group environment can also promote willingness to use exposure and to avoid using maladaptive coping behaviors.


    • Gil
      Nov 18, 2014 @ 10:42:32

      It does seem like age must be considered in the treatment of PTSD. A child may be more actively learning about the world and forming assumptions. There are protective factors a person has against PTSD. Having a lot of previously safe experiences with the situation and feeling in control during the situation can help prevent or reduce symptoms of PTSD. A younger individual may have less self-efficacy, coping skills, and fewer safe experiences. This leads to maladaptive interpretations of the meaning of trauma.


    • Sarah Gagne
      Nov 21, 2014 @ 21:54:27

      I agree that it can be helpful to identify stuck points of your own by viewing others in similar situations. Individuals tend to be biased, and even if others point out their own distortions they may not see them. Comparison is a powerful tool


  6. Paige Hartmann
    Nov 18, 2014 @ 20:48:10

    CBT treatment for eating disorders focuses on the cognitive factors that are responsible for the development and maintenance of the eating disorders themselves. Research has indicated that CBT is more effective in treating Bulimia Nervosa and Binge Eating Disorder than treating Anorexia Nervosa. The use of CBT for BN has shown about 50% of clients no longer bingeing and purging. In general, the use of CBT for treating AN has been understudied, but has been shown to be preferred in comparison to standard behavioral treatment. Group CBT treatment for BN was found to be equivalent to individual CBT treatment. The research on group CBT treatment for AN is limited, and has shown varying outcomes. One study demonstrated symptom reduction while another study did not indicate symptom reduction with the use of group CBT.

    Group exposure for PTSD can be effective as the members are exposed to other individuals who have experienced trauma, which helps to normalize their experiences. Individuals within the group directly explore and are exposed to the trauma in a safe manner. Through the use of trauma narratives, group members share their traumatic experience with the group while other members point out any distortions. Specifically within a group setting, members are able to offer support to one another during the exposure process.


  7. Sarah Gagne
    Nov 19, 2014 @ 18:01:17

    Research has shown that CBT is the most effective for bulimia currently and though there is little research on the topic, it is suspected that the same is true for anorexia. Research on group and individual therapy for bulimia has resulted in about 50% of individuals stopping their binging and purging behavior. Further, group treatment has been shown to be more effective in regards to abstinence than pharmacotherapy alone and CBT paired with pharmacotherapy. There are some considerations when administering group therapy for eating disorders, however. There are several, serious co-occurring issues with eating disorders that must be considered when running a group. For example, severe medical complications may prevent individuals from attending on a regular basis and damage the group dynamic and process. Drop-out rates have been shown in some research to be higher in group treatment than in individual treatment. Individuals with such intense self-image concerns may be uncomfortable; uncontrollably comparing themselves to others in a group setting. Additionally, motivation to change is crucial in CBT, and that is a large contributing factor to drop-out rates as improvement may mean weight gain. Individuals who improve will compare themselves to others who are not improving, i.e. staying unhealthily thin, and this may perpetuate the disease to become active again. As noted by Bieling, effective treatments should focus on others issues such as self-esteem, emotion regulation, and interpersonal issues.

    Group exposure for PTSD may be effective in that individuals with similar symptoms can come together in a safe environment, confront their trauma in a controlled manner, and have social support to deal with the aftermath. Group provides not only support, but a kind of effective peer pressure so that individuals cannot make up excuses to avoid their trauma as they are all in the same boat together. Individuals are able to challenge each other’s trauma narratives, and similar to treatment of others disorders such as social anxiety, challenges can be more powerful when heard from peers as opposed to therapists.


  8. Jessica
    Nov 19, 2014 @ 18:19:54

    Beiling et al. describe CBT as “front-line treatment for BN.” (p. 270). However, only half of participants studied cease binge eating and purging behaviors after CBT treatment, and the others show partial or no improvement. CBT with AN has been understudied, but studies show promise that is preferred over behavioral therapy and can lead to significant symptom reduction. Group CBT therapy can be particularly effective with people with eating disorders because these disorders tend to be very isolating and secretive, and a group can provide universality and support. Also the group can assist in challenging distorted thinking, and such evaluations I think would be more readily accepted by peers than by a therapist. However, a group setting may be detrimental if the group members are allowed to share specific binge eating and purging behaviors others can learn (this is true for any group with people with self harming behaviors). Also Beiling et al mention that members with very severe eating disorders are best served with individual care; I want to add that someone with a serious eating disorder is probably unable to attend fully to group material due to lack of energy and constant thoughts about food or weight. To some degree, that will also be present among those with more moderate eating disorders, perhaps explaining one reason this group could be hard to treat.
    CBT treatment for PTSD uses exposure, but of course it doesn’t expose the person to their actual trauma all over again, but exposes them to triggers to the PTSD symptoms and to memories of the trauma. These triggers are things associated with the trauma such as loud noises that resemble gunfire or explosions, consensual sexual acts that remind a rape survivor of a past rape, etc. The exposure to memories of the trauma seems to be common, but to what extent depends on the type of therapy.


  9. Michelle
    Nov 19, 2014 @ 18:20:10

    Beiling’s chapter of the efficacy of group CBT for the treatment of eating disorders somewhat surprised me. Prior to reading that chapter, I had heard that while CBT is effective for the treatment of a variety of disorders, it does not have especially good efficacy rates for this particular population. I am not sure about the reasons that CBT has not delivered optimal results for eating disorders, but do think that inclusion of family is an important part of the treatment that the research may be leaving out. Individual and group CBT, while offering a variety of interventions, does not focus specifically on familial issues, as does some of the family-oriented modes that I have heard about being more effective.
    However, this particular chapter delivers mixed results for efficacy for this population, indicating that even with the research results available, efficacy is inconclusive. While research with bulimic members indicated a higher dropout rate than in individual CBT treatment, members in this population experienced increased refrain from engaging in bulimic behavior. Research examining the efficacy of CBT group treatment for anorexia revealed inconclusive results. Overall, from what I had read previously, it appears that other modalities may be a better option. If not available, or if there are co-existing disorders that CBT may be beneficial for, CBT may be an option. Hopefully in the future we will learn more about the best ways to provide relief to this population.
    A critical element to the formation of a group focusing on PTSD is the inclusion and exclusion criteria used. Members will come to group with a variety of traumas, as some may have even been the perpetrator of an event or situation that led to one, while another was a victim of a crime. As group members share experiences, hearing about each other’s traumas can be triggers for their own experiences. During the selection process, group leaders should make it a point to ensure that selected members don’t have any conflicting traumas or other factors that could make exposure and group processing especially painful or distressing. Also important is the identification of the severity of symptoms related to the PTSD. Members should only be included if they are at a level where they are able to engage in group without repercussion, or issues that can instead of increasing functioning, become problematic.


    • Richard Hisman
      Nov 20, 2014 @ 08:50:37

      It should be recognized that most individuals are not developing PTSD from crimes. Other than rape victims most individuals will attempt to process through the effects of a crime with individuals they have relations with. One extreme example of those unable to do that is that of the soldier who was in a battle where he was required to return fire on a house that the enemy was ambushing them from. Upon entering the house at the end of the battle he found not only dead enemy but several dead women and children. This is a case where the soldier could not process or talk to others about the horrific scene he encountered. The soldier saw himself as a murderer. This may seem rare but it does draw similarities to 9/11. When we talk of similar traumas this points out not only the differences of the traumas but the ability to relate to what the individual has been through. The protection of the group may be the first time it has been verbally processed, so the group needs to be very accepting. Individuals who treat PTSD need to process what they are experiencing. Burnout amongst counselors at places like the VA is very high. It is not uncommon for counselors to last about 5 years in such facilities. This can affect the amount of follow up research being done, as well as the amount of therapists working in the field at any one time.


    • Jessica
      Nov 20, 2014 @ 10:48:37

      I also am surprised CBT did not receive better results with eating disorders, as it seems clear that automatic thoughts, cognitive distortions, and problematic behaviors are driving these disorders and what better treatment than CBT? However, we have to consider that people with eating disorders should have multiple modes of treatment, such as doctors, nutritionists, and therapists (ideally working as a team). Family should also be involved and environment plays such a key role in maintaining the disorder. It is not an easy disorder for therapy only to address and have much of any effect. Also CBT is very action oriented (and considering the serious health problems of these disorders, there is even more pressure by everyone involved to change the eating behavior), but most clients may not be ready to change, as they are often forced into treatment by their health problems and family members. Incorporating more motivational interviewing, and broader treatment focus including family, general self esteem, and emotional regulation (some DBT strategies such as mindfulness in regards to eating may be very helpful), may be more beneficial than traditional CBT.


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Adam M. Volungis, PhD, LMHC

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