This paper presents a theoretical reflection on a psychotherapy group formed for patients diagnosed with Anorexia Nervosa (DSM-5 code 307.1). It covers the group's member selection criteria, contract, boundaries, and process, as well as the four stages of group therapy — initial, transition, working, and final. The paper applies Yalom's eleven therapeutic factors to the group experience, evaluates group cohesiveness, and discusses the role of seating arrangements and session logs in monitoring progress. Self-System Therapy (SST) is also introduced as a supplementary intervention. The overarching goal is to improve treatment adherence and produce long-term behavioral and attitudinal change in members suffering from an eating disorder.
Group therapy is considered effective because groups support individuals who are in the same situation and face the same problems. They facilitate social skills and enhance discussion among people who learn from one another's experiences (Orenstein, 2014). Group therapy also costs less than individual counseling, since a collection of members sits together for treatment while gaining the shared learning experience of hearing how others have managed the same medical condition.
This paper provides a theoretical reflection on the group described here, covering its member selection criteria, group contract, boundaries and limitations, process and content, the stages of group therapy and how they are applied, Yalom's group concepts, and other relevant considerations. The group was formed to bring about changes in attitudes (Ezhumalai et al., 2018), which is one of its major aims. The change is expected to be long-term so that members achieve better health. The group serves as a means of helping and supporting selected members for a specific purpose. Because the group's functions are therapeutic — correcting disorder, educating members about their health condition, and inducing preventive measures into their daily routines to make adherence more convenient — it is also anticipated to bring positive change collectively rather than individually.
The group was created with certain guiding principles in mind: planned group formation, determining specific objectives to be attained, forming and maintaining relationships among members, flexible group functioning, and making progress by letting members voice their past experiences and evaluations (Ezhumalai et al., 2018).
The group was formed for psychotherapy purposes, bringing similar patients together for sessions, including those with a DSM-5 diagnosis for a specific health condition.
The criteria for member selection are the basic symptoms of the DSM-5 eating disorder, specifically Anorexia Nervosa, along with a need for help adhering to its treatment plan. The initial number of members planned for the group sessions is five, since a small group produces better-targeted results for all members equally (American Psychological Association, 2019).
The group contract encompasses patients who are committed to therapy for the stated medical condition and need an adherence strategy to reduce its signs and symptoms. Group members are expected to work toward mitigating the effects of the condition on their bodies, thinking abilities, and emotions. The group sessions aim to alleviate problems related to their eating disorder and enhance social skills so that communication helps soothe their suffering. Members are expected to listen to one another and observe what others in the same situation are going through. Maintaining confidentiality and building trust between the group session conductor and the members is therefore imperative for positive outcomes.
The boundaries set for the group involve both limitations and inclusiveness needs. The exclusion criteria cover individuals who are not suffering from Anorexia Nervosa — for example, those who are able to maintain a healthy weight or who may even be overweight — since these conditions do not fall under the DSM-5 definition of Anorexia Nervosa (American Psychiatric Association, n.d.).
The process and content of the group center on the health conditions affected by Anorexia Nervosa and its symptoms as they first occurred among the included members. Content covers signs and conditions such as food or energy intake below the body's actual requirements, extremely low body weight relative to what is needed for a healthy life, intense fear of gaining weight, and disturbed body image combined with a failure to recognize the seriousness of the condition (Body Matters, n.d.). Disturbed body composition is associated with decreased calorie intake, low fat storage, diminished fat tissue, low response to fat loss, self-starvation, malnutrition from a mismanaged diet, brittle hair and nails, wasting of heart muscle that could lead to heart failure or sudden death, vitamin and mineral deficiencies, and dehydration (Harrington et al., 2015).
Content also addresses the treatment plan, since most treatment for Anorexia Nervosa involves psychotherapy rather than medication. The DSM-5 code for Anorexia Nervosa is 307.1, restricting type (Academy for Eating Disorders, n.d.). Monitoring any possible improvement in eating disorder symptoms is essential, as even small progress indicates the effectiveness of group therapy and improvement in adherence to the treatment plan.
There are four stages of group therapy: the initial stage, the transition stage, the working stage, and the final stage (Live Rehab, n.d.). In the first stage, expectations were established for the group and its members. Members were expected to pursue betterment goals for their medical conditions, and confidentiality was made mandatory. Cultural considerations for each individual and their diverse backgrounds — which may affect group therapy outcomes — were also addressed. Personal beliefs and spiritual affiliations influence health condition outcomes (Shahin, Kennedy, & Stupans, 2019) and were therefore identified during this initial stage.
Next comes the transition stage, in which group members feel apprehensive about the consequences of the sessions. In this group, members were fearful of sharing their thoughts with strangers and concerned about others' perceptions of them. Some were shy and resistant to opening up. Although all members share the same DSM-5 diagnosis, a natural tendency toward limited participation was observed and was addressed as the sessions progressed.
The third stage is the working stage, in which deep connections with the group conductor and other members are established. This is the phase where participants become comfortable discussing issues in depth. Members' thoughts, feelings, and emotions were explored so that better solutions could be offered. Cultural and spiritual affiliations were kept in mind when suggesting personalized treatment interventions, and verbal and non-verbal cues were closely observed to encourage honesty and open communication.
The final stage can be understood as a consolidation or understanding stage, in which separation occurs alongside feelings of sadness. By this point, listening to others and engaging with their experiences has built genuine connections among members. Group members may form natural relationships through their shared knowledge and come to hold expectations for future health outcomes. Confidentiality remained in place, and the group conductor invited feedback. Success at this stage was measured by whether members found the sessions helpful and whether they experienced improved adherence to their treatment plan — primarily a psychotherapy intervention. Each member's performance contributed meaningfully to group objectives, with each progressing at their own pace.
"Eleven Yalom factors applied to group sessions"
"Catharsis, SST, and self-regulation improvements"
"Evidence of cohesion among group members"
"Circular seating, logs, and progress monitoring"
Orenstein, B. W. (2014, November 25). 6 benefits of group therapy for mental health treatment. Everyday Health. https://www.everydayhealth.com/news/benefits-group-therapy-mental-health-treatment/
Rickard, E., Hevey, D., & Wilson, C. (2020). The impact of seating arrangement and therapy task on therapeutic alliance formation. Counselling and Psychotherapy Research, 21(3), 683–696.
Shahin, W., Kennedy, G. A., & Stupans, I. (2019). The impact of personal and cultural beliefs on medication adherence of patients with chronic illnesses: A systematic review. Patient Preference and Adherence, 13, 1019–1035. https://doi.org/10.2147/PPA.S212046
Strauman, T. J., Goetz, E. L., Detloff, A. M., MacDuffie, K. E., Zaunmüller, L., & Lutz, W. (2013). Self-regulation and mechanisms of action in psychotherapy: A theory-based translational perspective. Journal of Personality, 81(6), 542–553.
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