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3. THERAPEUTIC GROUP WORK
EDQ runs two therapeutic groups – the 10-week therapeutic group and the Community Table. These groups are open to people of all genders from the age of 16 years.
10-Week Therapeutic Group:
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The 10-week therapeutic group aims to create a safe and supportive environment. This allows people to explore underlying reasons why they might be struggling with eating disorders. The groups cover a range of topics including feelings and needs, relationships and communication, body image and gender roles, cultural and family expectations. The group explores these different topics through discussions and expressivelybased therapeutic activities. These serve to increase insight and build support networks, skills and resources in the recovery journey. At EDQ the 10-week therapeutic group is run either in person or online via telehealth.
Community Table:
Community Table is a community-based meal support group for those who are recovering from an eating disorder. The group provides a safe, supportive environment where participants can work through the challenges associated with eating. The group is facilitated by qualified eating disorder practitioners and is a closed group of 6-8 individuals who meet once a week for 5 weeks. The group runs for 3 hours over the lunch period. The Community Table is designed for those with a variety of eating disorders. As a part of each session, the group shares a meal provided by EDQ. The group uses a semi-structured approach allowing time for pre- and post-meal activities as well as flexibility to explore a variety of different topics and skills that may be beneficial to recovery.
29. Ensure safety for participants at all times.
Safety is a primary principle of therapeutic group work. This includes safety for participants during the group sessions as well as skills and strategies to manage distress at other times when group facilitators are not present. Safety planning should be undertaken with all group participants and these plans should be adapted and reviewed when required.
Participants should be encouraged to access formal and informal supports during their participation in the group program. This may include access to individual counselling and support, as well as connection with peers and supportive family members and friends. Group members need clarity about the nature of confidentiality and the group agreement about these issues. For online groups this can present some complexities, but it is critical that confidentiality is discussed and agreed to.
One of the other key aspects of safety relates to language. It is important to discuss what language participants consider safe and what feels unsafe to them. There may be topics or discussions that some participants consider inappropriate and off limits. Trusting that disrespectful language or judgements will not be used can assist all participants in feeling safe to contribute and benefit from the group.
30. Create a warm and welcoming environment.
It is a well-established principle that creating a warm and welcoming environment enables a sense of safety for group participants. The group environment should be accessible and comfortable. Many things that can be done to ensure that the environment is informal and non-clinical. For example, the use of plants, diffusers, a variety of seating options, all assist in creating a sense of comfort and ease.
31. The intake and assessment process should ensure the group is inclusive of all people and their experiences.
Therapeutic groups have a specific focus and purpose, and this should be clearly explained to participants during the intake process. The intake process should be a time when participants learn about the nature of the group and the facilitators learn about the goals and expectations of the participants 59 .
In general, therapeutic groups for people with eating disorders should achieve a balance between incorporating a range of different presentations while also being mindful of the connections that are formed from sharing similar experiences. While the intake process aims to ensure inclusivity of all people and their eating disorders, this must be balanced with each person’s readiness for group work and their stage of recovery.
Risk assessment is a key part of the intake and assessment process and should be undertake in consultation with the person seeking to join the group.
32. Group sessions are recovery focused and ensure high levels of client empowerment, choice and participation.
The invaluable therapeutic benefits, relative costeffectiveness, and short-term duration of many groups arguably distinguish this healing modality as a critical and primary source of therapeutic intervention 60 .
Group work is a particularly useful approach in working with people with eating disorders from a feminist perspective given the possibilities for minimising power imbalances and increasing client control and empowerment. Given the importance of these issues for people with an eating disorder, group participants are invited to participate in all aspects of the therapeutic group from setting up, choosing activities and deciding on their level of participation in the group. Decision making is ideally shared between facilitators and group members in an equitable and balanced way. It is important that participants have a shared sense of ownership of the group.
The therapeutic group is recovery focused and clients are invited to think about what recovery means for them. Group participants are encouraged to share their stories in whatever way they feel is most suited to them.
Again, the level of their participation is their choice and group members are empowered to make their own decisions about their contribution. Group facilitators should intentionally engage participants to highlight their shared experiences and learnings so that a greater understanding of their eating disorders is developed in the group.
The group should provide space for connection between participants and to allow the group dynamics to develop over time. At times the facilitators will intervene to ensure there is safety in the group, and at other times they will allow the group to self-regulate.
33. Groups build a sense of community and storytelling.
The sense of community created in the groups and the story sharing by participants support people to counter the sense of shame, guilt and isolation that can come with an eating disorder. Connection, relationships and support are key features of recovery from eating disorders given the many ways in which eating disorders inherently disconnect people from their existing support systems 61 .
Given the length of time participants are together, the development of group cohesion and understanding assists in establishing a sense of community within an organisation. This is important as clients will ideally move between the different services which are offered at different times in their recovery journey.
Group work enables women (sic) to come together to support one another and create a counterculture where diversity is accepted and celebrated and competition is challenged 62 .
34. Group content and process should reflect key themes for clients and include the use of a range of different mediums for expression.
The structure for the 10-week therapeutic group should include a focus on group process and building relationships within the group. This is a central aim of the group given the importance of connection and community. It is also an important way of ensuring safety in the group. Facilitators must ensure that participants feel safe to openly express their feelings in the group as they share emotional aspects of their story. There must be a recognition of the courage it takes to become vulnerable in front of others when we share our story 63 .
In addition to this, the group should explore issues that are relevant to participant’s experiences such as:
• Awareness of our bodies. • Our relationship with ourselves and how we feel about ourselves. • Awareness of the relationship between our feelings and our bodies. • Getting to know our inner nurturer. • Grounding and mindfulness. • Understanding emotions and personal issues and how these might contribute to food, body and weight issues. • Recognising our internal critical voice and the role it plays in the eating disorder. • How gender roles, cultural and family expectations might influence the development of an eating disorder. • Why diets don’t work. • Understanding that recovery is a process.
Similarly, to individual therapeutic work, research has found that the use of creative and expressive therapies in group therapy for people with eating disorders is a highly effective means of expression and connection 64 .
A wide variety of different mediums that can be easily employed in group work to assist participants to safely express themselves and share their stories. Mediums such as art 65 , movement 66 , and music 67 , provide accessible ways of connecting to and expressing emotions.
35. Facilitators must be aware of group dynamics and the importance of clear boundaries
Therapeutic groups should always be co-facilitated. The facilitators’ role is primarily to ensure a safe space for participants and to ensure that the group meets its overall purpose. A certain degree of flexibility and spontaneity is required so that the process can evolve organically in addition to meeting the plan for the session. Facilitators need to ensure consistency and predictability and combine this with an informal and warm approach.
It is important that facilitators are clear about their role and appropriate boundaries. In the spirit of minimising power imbalances, facilitators will participate in group activities and at times, share parts of their story and their own lived experience when it is considered both relevant and helpful to the discussion. Feministoriented groups view power and leadership as being shared among members and facilitators who are all considered to be experts of their own experience 68 .
Facilitators should brief and debrief together before and after each session. These interactions will inform the process and structure of the following sessions as well as ensuring that client safety is maintained including a level of engagement in the group.
Given the complex nature of eating disorders, whether the eating behaviour improves is not the best measure of how useful the group has been. For many people, becoming aware of how they feel can result in the eating behaviour worsening as the underlying issues resulting in these eating behaviours are explored.
