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Body Dysmorphic Disorder Techniques for Treating Obesessions with Body Perfection
Body Dysmorphic Disorder: Diagnosis & Treatment - 10 CEUs

Section 26
Integrative Group Psychotherapy for BDD, Part II

CEU Question 26 | CE Test | Table of Contents | Body Dysmorphia
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The Method: Five Phases
Traditional cotherapy preparation work followed. Cotherapists met several times in advance of the first meeting and discussed the group format and their role definitions. Since the T'ai Chi instructor was not a psychotherapist, clear boundaries were defined as to the level of her verbal input. The author ran the sessions. The T'ai Chi instructor was introduced as an expert in movement and body work. Although the T'ai Chi instructor did not interpret emotional material, she could and did share her reactions with group members in reference to movement. Movement is central throughout all five phases. All sessions began or ended with thirty minutes of movement. Sometimes movement was used during the sessions in order to highlight a point.

Phase I--Introduction and Evaluation
The contract and therapeutic agenda were introduced. (Patients were given handouts (Tables IV, V) and asked to bring them to group the following week. The goal of Phase I was to develop a therapeutic alliance, foster self-disclosure, destigmatize weight and size, and to get baseline drawings (as discussed below). The T'ai Chi expert was introduced and a contract about movement and touch was set. All instructions regarding movement were done verbally and through demonstration. If a physical position was to be corrected, the instructor asked permission to "put hands on the patient." The patient could deny permission. Thirty minutes of each session either began or ended with several T'ai Chi movements. The group language was purposely modified to focus on metaphors for eating. Food was translated into a language of emotions, i.e. feelings and relationships. Eating was put into a different frame, i.e., problems of self soothing and connection with the love object. The initial phase of the group (Weeks one to four) was spent diagnosing the problem, not just in words and description, but through a series of drawings. In my original work in the Body Image Workshop I had developed a series of 12 Projective Drawings which could quickly get to unconscious material and identify roadblocks to weight loss and the genesis of negative Body Image. These 12 projective drawings are used throughout the five phases.

In the first session it was important to get a base line of these drawings (Drawings 1, 2, 3, and the sculpting exercise) before patients began deconstructing their story and began the treatment process. These drawings later would be used for comparison in Phase V. In the first group they discussed: 1. Why they were participating in the Workshop. 2. When their problem began. 3. The need to eat; distinguishing eating out of hunger or out of the need to be soothed emotionally. 4. How the legacy of parental over or under stimulation and/or involvement left them with a legacy of defective self-regulation. 5. How eating was a primitive connection with their mother, and how they never learned to soothe themselves adequately. 6. Their struggle against the so called "food addictions." 7. Becoming familiar with information about the latest research in obesity.

In Phase I an assessment was made regarding the patients motivation to change as well as their personal meaning of eating. These were assessed through a series of questions: Why are you interested in exploring your body image now? Are you satisfied with your current weight? Why is your weight and/or body image a problem? What made you want to come to treatment? What, apart from your weight/body image do you want to change about yourself? What are the advantages and disadvantages to being fat and thin? How does your weight get in the way of your daffy life and in the way of your relations with men and women? Has your weight always affected you in this way? What is the personal meaning of eating? What is your fantasy life? What would life be like for you if you could manage to do what you say you want to do? When you last lost weight, what happened? Did your concept of self change? Thus, the patient's perception of self through a group psychotherapy dynamic evolved. As well as motivation, Patient's "Weight Zones" are defined. The concept of "Weight Zones" offers a structure to think about one's weight. Patients are offered the option to return to any level or zone of weight where they feel safe in order to do the developmental work needed at any one given time. This could literally mean gaining weight until they felt safe. This working definition of weight sets a frame of control and safety.

Phase II --Externalized Objects
The goal of this phase is to 1. Deconstruct and discuss one's perception of self in reference to externalized objects through drawings and 2. to further explore one's body perimeters through body sculpting, i.e., guided touch, along with the specific T'ai Chi movements. The T'ai Chi instructor demonstrates guided visualization and guided movement with a focus to anatomy and body stance. The analysis of externalized objects in group members lives is derived from Drawings 4, 5, 6, 7, 8. Group-as-a-whole methods are used, integrating the progressive use of the 12 projective drawings through group process. The use of discussion of the drawings and the specific movements taught by the T'ai Chi instructor create the mainframe and boundary of the work of the group. In the short model, Phase II is three-to-four-weeks-long. In the long model, this is the middle part of the group which can go on for weeks depending upon patient response. The T'ai Chi instructor introduces anatomical instruction demonstrated on a skeletal model. I review for the group normal development of body image; understanding the development of their body image distortion in their family of origin, and developmental milestones of separation and individuation. During this phase members are very interactive with each other in the group process. Members are encouraged to comment on each others drawings and to discuss the feelings that arise from seeing and experiencing the drawings. The timing of the introduction of new material was geared according to patient response.

Appropriate timing for each group was always a challenge. The goal was not to flood patients with too much interpretation and too much new material. This required the sophistication of a trained group therapy professional. The first or last 30 minutes of each group session during Phase II was devoted to a form of movement. We reviewed what their experiences were out in the world. Why is body image so important to them? What is it that they hope to achieve? Why are eating and looks so important to them? What is their goal in social life? Where are they regarding others? Did they have hopes of attachment? Why hasn't that happened? During this phase the following were reviewed and discussed: 1. The psychoeducational piece starting with anatomical instruction. 2. The view of normative discontent in society-at-large. 3. Concepts of body image and body image development were explored, as well as the concept of eating as a primitive connection with mother. 4. Fat described as a symptom of emotional conflict. 5. It was suggested that the goal of eating may not be to get fat. Fat may be the result of a complicated process. 6. Eating may be part and partial of a primitive method of soothing and incorporating the love object. 7. Eating is a defense mechanism which is caloric and leads to being overweight or "fat." Eating may be in response to feelings that they feel they could not contain, i.e., emptiness, fear, anxiety, sadness. 8. The need to eat is very complicated, if one takes into account the biological mechanisms behind it, i.e., fat cell morphology and the physiological set up. 9. Normal growth and developmental factors in family life are discussed. Similarly, cultural mandates, fears about growing up, separation and individuation, and differentiating one's self from others are also focal points of discussion.

Phase III--Internalized Objects
The goal of Phase III is to study the interaction between the patient and their parents. Movement therapy is continued to correct their view of their actual size, weight, and attitude through relearning their body boundaries.

Phase III is an introduction to their internal world. What has been developed over time from birth through young adulthood as an internalized object/and then how has that been projected out into the world? Drawings were done of the internalized object, parents, and therapist. For the short-term model, Phase III took place over the last four to five weeks of the group. As in Phase II, the first 30 minutes of each group session was devoted to movement. This was the most poignant and powerful phase of the group experience. It was when group members felt the most vulnerable and unsafe. It was essential that the therapist was mindful that the group maintained strong boundaries and containment of intense emotions during this phase. A representative sampling of techniques used in this phase are guided visualizations and gestalt chair work. Patients brought in family photos from when they were young. Group discussion consisted of 1. self assessment, i.e., a review of the reality of what each patient looked like when younger. 2. Assessment of the other's pictures. 3. Gestalt/chair work was introduced after review of the pictures. The group worked as a team, designating two people to role play the parent and the child in the pictures. The two, who represented the child, chose who they wanted on their team to shadow and coach them in responding to the person in the dyad who functioned in the role of the judgmental, negative parent. Patients then reversed roles. In the short-term model, there was time for only one or two demonstrations, but all patients got to work the dyad with the group dividing into teams. A sample of the questions explored in this phase are: 1. What did they learn in their families about separation? Could their parents let them go? Did any one parent prevent them from being launched? 2. What did they learn about their own sexuality? 3. Were they raised so that they could "strut their stuff?" Could they beat out the parent? 4. What picture of self did their parents give them? 5. What did their parents like about them? 6. What didn't they like? Issues of competition, guilt, love, hate, and aggression were discussed. 7. Patients were asked to bring in family photos. 8. The notion of projection was introduced. What feedback do group members get when they are out in the world? 9. They were asked to imagine how life would be different when and if they lost weight. What do they want to be different? What was it like in the group?

PhaseIV--Pre. Termination
The goal of this phase is 1. Evaluate patient progress regarding the integration of the emotional material learned and its translation towards their perception of self. 2. Evaluate any change they've made in feeling more integrated in "their own skin" in size, shape, and attitude. 3. Begin entering into the Termination Phase of the group. As the group enters into the termination phase they begin to review the shared experiences of group members. They can choose to return to any phase of the group to look again at any material they feel they need to. As they continue to work with the T'ai Chi instructor they can continue to comment on their progress as they take a more realistic view of their bodies. During this phase there was a guided meditation of a beach scene. This fantasy walked patients through their negative and ambivalent feelings of their parents to negotiating with their parents and speaking up for themselves. The parent listened, or the patient grappled with the fact that the parent never listened. Patients learned that they must separate from their family of origin. The session ended with a rapprochement between the two.

Phase V--Termination and Review
The goal of termination is to review the patient's progress and work and to give closure to group members. This phase can last for two to three weeks. In the last phase of the group patients are asked to redo all of the drawings and the sculpting exercise described in Table II, and compare their original drawings to these new drawings. Termination encompassed a review of what they learned and assessed their need for further treatment. A group follow-up meeting was planned for six months later.

The Integrated Model for Group Psychotherapy has proven to be an innovative and successful way to apply group techniques to ODE adults with BID. The advantage of a group model for working with BID's is that there are multi mirrors, i.e. multi object reflection using projection and transference. Transference involves all group participants, including the T'ai Chi instructor. I observed some of the valuable elements frequently found in homogeneous groups--more rapid emergence of transferential issues, greater level of self-disclosure, and more cross identification. The group was homogeneous by problem selection, but the members had different psychostructural organizations. In these groups the more developed patients, having a later age of onset, were able to model and give feedback of a healthier perception of self. Even those who had childhood onset of obesity and had self distortions could have great clarity when observing the size, shape, and self-loathing of someone else. Some served as parental stand-ins, both positive and negative. From a cultural standpoint, most overweight patients suffer from negative input from peers and the culture at large. As body dissatisfaction and weight concerns become increasingly normative among women in Westernized countries it becomes harder to differentiate pathological concern from cultural norms.

Motivation and empathy were quickly addressed. The management of intense affect emerged as a group theme, in particular anger, a prevailing emotion, and its appropriate expression. The group allowed a greater expression of feeling than in individual therapy. The group it seemed, provided a safer place than individual therapy. The group could hold each other's anger, process and contain it.
By the end of the Group, there was a reduction in anger and a greater ability to address separation and individuation, allowing patients to begin looking at their parents objectively. Main themes emerged: boundary issues with parents, enmeshment, and identifying the parenting child. Group members were able to address the difference between feeling compassion for their parents, which requires separateness, as opposed to being enmeshed and breathing through another's lungs. Group members were stunned by their level of rage, jealousy, and shame. The power of the group experience facilitated their awareness of what their needs were. They experienced a huge sense of relief that others had the same problems and that they weren't "crazy." The sculpting exercise and movement addressed their body dissociation. Towards the end of the Workshop, some members expressed that they "felt thin" and had less attachment and emphasis on negativity. Some became more accepting of themselves and their bodies. They were relieved to not have to focus on having to lose weight to succeed in life. There was relief at gaining some understanding of the development of body image. They were less fearful of their bodies. There seemed to be an integration of body and mind. When determining weight zones, it became obvious to these patients that some of their belief systems were contradictory to the logic of the numbers in weight which they attached to each zone.

The exploration of "when did the problem begin?" helped patients decode their potential secondary gains for not losing weight. The family photos were a useful tool that challenged their memory of self-image. Their expression of shock in the discrepancy between their memory and the pictures was powerful. Many who thought they were fat and ugly as children were surprised at the positive feedback they had from other group members. Identification of their enmeshed family structure became central. More specifically, a pattern of intense mother-daughter relationship was noteworthy. Making use of the power of the group to find the strength to begin the process of being launched from their family of origin became a central theme. Many came to understand that the root of their conflicts was grounded in the sexual arena. This encompassed their competition with mother, individuation and separation from mother; their being a stand in for mother with father or father with mother. The challenge was to come to terms with their sexuality and not be fearful of it. The overweight men had to come to terms with others' perception of them as androgynous, non sexual. Group members were able to reflect a reality that demonstrated how far afield parents' perceptions of their children were. They could see themselves through others' eyes. Clearly identified were the areas of developmental arrest and parental empathic failure. Eventually some could forgive themselves for the neglect of their bodies. Some could forgive their parents and strike a more balanced appreciation for the task of parenting. The group model seemed to provide what Yalom calls the eleven primary categories of curative factors.

Group is an effective modality to treat body image disturbances with the disordered eating population. Throughout the process, it became clear that these patients needed to address their need to be launched from their family of origin and the group was a facilitator in this process. In essence, siblings could help each other develop and grow. Their level of self acceptance was raised. Many went on to exercise classes. Several decided that they no longer needed to lose weight and that they could be content with themselves as they were. Several continued more rigorously to lose weight. All reported that the Group had a strong impact on their lives. All remarked that they never had felt so powerful as when they followed the T'ai Chi technique. The speed of self integration was facilitated much more than solely in individual treatment. The Integrated Group Psychotherapy Model is a starting point to work with obese patients whose lives have become limited by their misperceptions of self in size and attitude. The work is based upon my many years of clinical experience in this field. My work provides an opportunity for further study which goes beyond talk therapy in the attempt to change body image and challenges traditional theoretical and practical approaches to body image disturbance.
- Weiss, Fran, Group Psychotherapy with Obese Disordered-Eating Adults with Body-Image Disturbances: An Integrated Model, American Journal of Psychotherapy, 00029564, 2004, Vol. 58, Issue 3

Personal Reflection Exercise #12
The preceding section contained information regarding strategies for integrative group psychotherapy for BDD.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Shanok, N. A., Reive, C., Mize, K. D., & Jones, N. A. (2020). Mindfulness meditation intervention alters neurophysiological symptoms of anxiety and depression in preadolescents. Journal of Psychophysiology, 34(3), 159–170.

Stanley, B., Currier, G. W., Chesin, M., Chaudhury, S., Jager-Hyman, S., Gafalvy, H., & Brown, G. K. (2018). Suicidal behavior and non-suicidal self-injury in emergency departments underestimated by administrative claims data. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(5), 318–325.

Summers, B. J., & Cougle, J. R. (2018). An experimental test of the role of appearance-related safety behaviors in body dysmorphic disorder, social anxiety, and body dissatisfaction. Journal of Abnormal Psychology, 127(8), 770–780.

Online Continuing Education QUESTION 26
What are the five phases in integrative group psychotherapy for BDD? Record the letter of the correct answer the CE Test.

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