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Running head: PSYCHOEDUCATIONAL THERAPY GROUP FOR FEMALE COLLEGE STUDENTS WITH EATING DISORDERS

Psychoeducational Therapy Group for Female College Students with Eating Disorders

Zachary Boston, Saundra Burleson, Elizabeth Turner

CNS742: Group Procedures in Counseling

Instructor: Dr. Jennifer Rogers

Wake Forest University

June 21, 2014

Psychoeducational Therapy Group

Table of Contents

SectionPage

Group Objectives 3

Informed Consent 4

Plans for 6 Group Sessions

Session 1: Purpose of Group 5

Session 2: Establishing Goals and Setting Objectives 6

Session 3: A Look at Nutrition Through Interactive Cooking as a Part of 7

Session 4: Learning Positive Life Skills 8

Session 4: Mirror, Mirror on the Wall 9

Session 5: How Much Does Another Person’s Opinion Matter? 10

Session 6: The “Last” Supper 11

Outcome Evaluation Questionnaire 13

Resources for Group Members 14

Resources for Group Leaders 17

Issues in Application 18

References 21

Attachment 1/Self-Esteem Inventory of Positives 23

Attachment 2/Personal Coat of Arms 24

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Group Objectives

1. To prevent future development of eating disorders.

2. To develop and strengthen coping skills for dealing with the stresses of being a

female collegiate athlete.

3. To develop a higher level of self-esteem.

4. To learn about resources available both on and off campus which will provide

information and support to group members.

5. To gain better knowledge and understanding about sports nutrition and what a

collegiate female athlete needs to function properly.

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Informed Consent Statement

I, _______________________, acknowledge that group counseling is an activity that involves

my being open, honest, and willing to participate with others. My goal is to attempt to reach

personal and group goals with the other members. There is a likelihood of negative and positive

feelings experienced throughout this process. I pledge to work hard in the group while

collaborating with the group leader and other members when it comes to discussions and group

exercises.

Group Member Signature: __________________________________________

Date: __________________________________________

Parent Signature (If required): __________________________________________

Date: __________________________________________

Group Leader Signature: __________________________________________

Date: __________________________________________

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Plans for 6 Group Sessions

Session 1: Purpose of Group

1. Leader will state the purpose of the group which is providing skills, knowledge and

support to each other in overcoming eating disorders.

a. Educational materials in reference to the importance of appropriate nutritional

foods and amounts of foods required for female collegiate athletes; will be

provided to each group member along with a Consent form which they are

instructed to sign and leave on the desk on the way out..

b. Guest Nutritionist will speak to the group about healthy foods and daily

requirements for collegiate female athletes.

c. Index cards will be given out to group members. Each group member is then

instructed to write down one goal that they would like to achieve by participating

in this group.

2. Getting to Know Each Other

a. Women will begin by introducing themselves.

i. What they are studying in school.

ii. Where they are from.

iii. What profession they are interested in.

iv. They will read the goal they have written on the index card.

3. Group Leader Begins Closure of Session

a. Gives out Self-Esteem Worksheet One and instructs group to complete this for

“homework” and bring back in to next session.

b. Asks group how they feel about embarking on this journey.

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c. Wraps up meeting with a positive message and dismisses group.

Supplies needed for Week 1: Index Cards, Consent Forms, Self-Inventoy

Worksheet (Attachment 1)

Session 2: Establishing Goals & Setting Objectives

1. Group Leader welcomes group and brings up the topic of the goals that were set last

week (index cards).

2. Invites group members to share what they are thinking about that at the moment. And if

the homework they completed brought up anything for them.

3. Post it Notes

a. Group members will write words that they use to describe themselves on post it

notes. They can use any adjective they wish, but they do not write their name on

the post it note.

b. The notes will be collected in a basket and then mixed up so that group members

will not be self-conscious about what they wrote.

c. Group Leader will place all post it notes up on a board at the front of the room

where all members can see them.

d. Group members will have an opportunity to look at all of the words used to

describe themselves.

e. Go around and ask what are their initial reactions to the words they view.

f. Ask open-ended questions to bring the members into conversation about the

power of words. What do words do to us? How do they affect us? How can we

positively and negatively use words?

4. Use the post it note discussion as a catalyst for self-disclosure.

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a. Reiterate importance of confidentiality.

b. Ask the group for their thoughts.

c. What are the concerns

d. What are the fears

e. What are the hopes

5. Give a brief description of what will happen next week.

6. Dismissal of group

Materials needed: Post it notes, poster board, pens/pencils

Session 3: A Look At Nutrition Through Interactive Cooking As A Part Of Learning

Positive Life-Skills.

1. Nutrition is a key role in keeping athletes healthy and performing at their best. Sadly,

some do not know how to appropriately feed their bodies and with the increased pressure

to drink, stay up all hours of the day and night, and eat cold pizza. How do you stay

healthy in college? How do you navigate the cafeteria? How do you stay in peak health

nutritionally speaking?

2. A lesson in Science

a. We will look at calories in vs. calories out.

b. What are good calories and what are bad calories.

c. What do they already know about nutrition.

d. Debunking myths about nutrition.

3. A lesson in surviving college food

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a. There is a lot of pressure to maintain top physical performance as a female

collegiate athlete. There is also tremendous pressure to fit in with peers through

outside social structures.

b. There is lots of drinking. There is lots of late night snacking.

c. How do athletes maintain that top physical health while still maintaining a social

life? How do these pressures lead athletes to poor eating habits and eating

disorders? What are some of the coping skills necessary to get through this time?

d. Engage the athletes in a time of discussion about their eating habits. When do

they eat normally? What types of foods do they eat? What are some of the ways

that they make those decisions?

4. A game in portion control and right choices

a. Around the room there will be set up a series of different foods. The foods will be

in different containers. For example you might have a ½ cup of rice in a large

bowl and ½ cup of rice on a small plate. This will be the same for various types

of foods.

b. Athletes will go around the room looking at the various types of food and try and

guess 3 things: 1, how much it is; 2, how many calories are in it; 3, is this

beneficial to my overall health?

c. They will all come back and share with the group what they think the answers are.

d. Share with them the correct answers. Talk about any questions about the items

5. The Lesson

a. Talk about how knowledge is power.

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b. When you know what you are eating and how it affects your body, you are able to

make appropriate decisions.

c. Reiterate the fact that just because you have a bad night and eat pizza late at night

it’s not the end of the world. Learn ways to make better choices and improve on

those the next day.

6. Wrapping up

a. Follow up with any questions that the group members might have.

b. Give a brief overview of next week.

c. Dismiss the group

Materials needed: various sizes of plates, cups, and bowls; various types of food; nutrition

breakdown of foods; pens/pencils; paper

Session 4: Mirror, Mirror on the wall

1. Welcome

2. Recap of last week

a. Ask group members if they were able to effectively implement any of what they

have learned so far.

b. What has been one thing that you have learned about yourself since the first

sessions?

c. How has what you learned so far differed from what you’ve been taught in the

past?

3. What do you like/dislike about yourself?

a. Each person needs to name one thing that they dislike about themselves.

Generally speaking, everyone has a least one area that they hate about themselves

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or wish that they could change. It is time to name that and look at how they can

move past that.

b. There is one thing that most people like about themselves. What is that one

thing? How can you focus on the positive?

4. Check in with everyone; let them know that there are only two more sessions and then

dismiss the group.

Session 5: How Much Does Another Person’s Opinion of You Really Matter?

1. How do others view you?

a. For this exercise everyone will write her name on the top of the paper.

a. It will be passed around in a circle and each person will write on the paper

something positive about the other person.

b. The group will then spend some time reading over their “warm fuzzies”.

5. Discussion

a. What do others see in you that you don’t see in yourself?

b. How can you begin to see what others see in you?

c. What are you beginning to see about yourself that will make a difference in how

to conduct your life overall through eating, sports, academics, relationships, etc?

6. Your Crest

a. This will be a takeaway project for them hold on to and remember the values that

they find most important

b. They will be given a crest (attached) and asked to write down 6 things that are

important to them and that drive them to be a better person.

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c. They could also write down 6 struggles that they feel like they now have the

knowledge and skills necessary to help them overcome them.

7. Instruct the group members that you are going to have a “mock” Pot Luck dinner next

week. Let them know that their homework is to get in contact with the other group

members via telephone, texting, or email, sometime over the next week and plan a

“menu” of homemade dishes that they will bring to your final group session for a

celebration dinner. Let them know that this is their responsibility to plan this pretend

“meal” for their group. The items that they choose to bring, collectively, must comprise a

healthy, nutritional, meal, appropriate for a group of collegiate female athletes. They

must bring a written copy of the recipe to their homemade dish with them but they do not

really have to bring the dish (this is pretend.)

8. Check in with group members. Let them know that the next meeting will be the last so

that they can be more prepared. Wrap up and dismiss the group.

Materials needed: Paper, pens, markers/crayons, and crest picture (Attachment 2).

Session 6: The “Last” Supper

1. Welcome group members and open up session by asking if there are any important items

that need to be clarified or dealt with now.

2. Ask group members to go to the “dining” table that you have set up in the room and place

their recipe card on the table. As members stand around the table, initiate a discussion and have

each member describe the “recipe” they brought and then let the group give their thoughts about

how that recipe sounds to them; how the meal appears to them; and their thoughts on whether

they think they could adapt their dietary behavior to a meal like this.

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3. Thank the group for their participation; leave them with a positive message about their

hard work and progress and some information about resources they can use if they are struggling.

4. Say goodbyes, give them an Evaluation Questionnare and ask them to stick it in the mail

to you this week and dismiss the group for the final time.

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Outcome Evaluation Questionnaire

1. What are your overall feelings about the experience you had in this group?

2. Do you feel the tools and resources provided are resources you can utilize if needed?

3. When it comes to nutrition:

Are you aware of the consequences of poor nutritional practices?

Can you recognize good and bad nutritional choices?

Will you use this knowledge to make more educated choices in regards to foods and

nutrition?

4. Did the group leader exemplify behaviors fitting of a quality leader? (knowledge,

compassion, leading towards positive outcomes)

5. Do you feel that you are well prepared to reenter the athletic world; now that you know

more about the requirements of healthy nutrition?

6. What was the most positive piece of information you learned in your time with the

group?

7. What could be improved in the group? If nothing, why not?

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Resources for Group Members

1. Tips for parents of a child with an eating disorder

It can be deeply distressing for a parent to know that their child is struggling with an

eating disorder. As well as ensuring your child receives the professional help he or she

needs, here are some other tips:

a. Examine your own attitudes about food, weight, body image and body size.

Think about the way you personally are affected by body-image pressures, and share these with

your child.

b. Avoid threats, scare tactics, angry outbursts, and put-downs. Bear in mind

that an eating disorder is often a symptom to extreme emotional and stress, an attempt to manage

emotional pain, stress, and/or self-hate. Negative communication will only make it worse.

c. Set caring and consistent limits for your child. For example, know how you

will respond when your child wants to skip meals or eat alone, or when they get angry if

someone eats their "special" food.

d. Remain firm. Regardless of pleas to "not make me," and promises that the

behavior will stop, you have to stay very attuned to what is happening with your child and may

have to force them to go to the doctor or the hospital. Keep in mind how serious eating disorders

are.

e. Do whatever you can to promote self-esteem in your child in intellectual,

athletic, and social endeavors. Give boys and girls the same opportunities and encouragement. A

well-rounded sense of self and solid self-esteem are perhaps the best antidotes to disordered

eating.

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f. Encourage your child to find healthy ways to manage unpleasant

feelings such as stress, anxiety, depression, loneliness, or self-hatred.

g. Remember it's not your fault. Parents often feel they must take on responsibility

for the eating disorder, which is something they truly have no control over. Once you can accept

that the eating disorder is not anyone's fault, you can be freed to take action that is honest and not

clouded by what you "should" or "could" have done.

Adapted from: National Eating Disorders Association

2. Foundations Family Nutrition

Provides nutritional services to adults and adolescents. Dieticians also specialize in

athletic diets. These counselors can provide education on specialized diets for what

athletes need for performance and health. Dieticians can assist with weight management.

Motivating Behavior Change

Endurance and Ultra Endurance Athletes

Strength and Power Athletes

Rehabilitating Athletes

(Foundations Family Nutrition, 2013)

3. McCallum Place Eating Disorder Centers

This institution focuses on Anorexia Athletica. Anorexia in females in athletics.

“McCallum Place is a nationally accredited eating disorder treatment center dedicated to

helping those suffering from an eating disorder find recovery. We specialize in treating

not only eating disorders but the individual as a whole, unique being” (McCallum Place

Eating Disorder Centers, 2014)

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4. Psychological Reasons For Eating Disorders

Recovery for athletes with eating disorders without treatment is unlikely.

Without treatment, the athlete can become isolated.

Over time, the athlete will deteriorate physically and psychologically.

Performance in athletes with eating disorders is eventually negatively affected.

Poorer performance increases pressure on the athlete.

The disorder is apt to be the athlete’s way to deal with pressure.

An increase in pressure on the athlete increases the need for the disorder.

5. Medical Reasons

• Medical complications are common and potentially life-threatening in athletes with

eating disorders.

• Many athletes with eating disorders and anorexia athletica have fluid, electrolyte, and

energy imbalances, increasing the risk of cardiovascular compromise while competing.

• Postponing treatment can lead to worse outcomes.

Malnutrition has a significant impact on thinking in athletes with eating disorders -

affecting concentration, the ability to see things in context, and impair judgment.

Malnutrition can lead to both brittle bones and metabolic compromise and increased risk

of musculoskeletal injury.

A compulsion to exercise and over train may make stabilization difficult in athletes with

eating disorders without structure and support.

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6. NEDA Parent Toolkit

This PDF File includes tools for parents to understand and support a family member

suffering from an eating disorder. (Attachment)

Resources for Group Leaders

1. General education and expertise in reference to the conditions listed under the general

term “Eating Disorders.” Knowledge is key to understanding where these women are coming

from in their own unique situations.

2. Summit Psychological Services provides extensive training and certifications in working with women with Eating Disorders.

3. International Association of Eating Disorders (IAEDP) provides “first-quality education

and high-level training standards to an international multidisciplinary group of various healthcare

treatment providers and helping professions, who treat the full spectrum of eating disorder

problems.” (International Association of Eating Disorders, 2014)

4. American Counseling Association

5. North Carolina Counseling Association

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Issues in Application

Each of the three members of the group who participated in this project are working

toward a Master of Arts in Counseling and have expressed that they anticipate or have set the

goal to work in a variety of settings. Although the three members of this group are anticipating

that they will work with three significantly different populations, the following information will

describe how conducting the group described in this assignment would be practical. For the

purposes of the Issues in Application section of this assignment, I will refer to the three group

members who participated in completing this assignment as Student 1, Student 2, and Student 3.

Student 1 anticipates working with young girls with a variety of mental health issues in

private practice. While collegiate female athletes would not be included in the age group of the

girls that Student 1 anticipates working with; it is possible that minor modifications could be

made to the format to make it suitable as an effective preventive measure for young girls with

self-esteem or body image issues who could potentially develop an eating disorder. In statistics

given based on a survey conducted in 1991 (with a significant increase in recent years due to

worldwide access to the internet, including video and social websites) it is noted that “47% of

girls in the 5th-12th grade reported wanting to lose weight because of magazine pictures. 69% of

girls in 5th-12th grade reported that magazine pictures influenced their idea of a perfect body

shape. 42% of 1st-3rd grade girls want to be thinner.” (Collins, 1991) The number of group

members allowed may need to be modified since there are typically fewer members in a

children’s group than in an adult’s group. Working with young girls in a group like this (with

material modified for age appropriateness) may be an effective way of proactively educating

them in an effort to prevent future problems. Many of the references accessed in researching for

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this project give statements regarding the importance of prevention in helping to decrease the

number of female athletes with eating disorders.

Student 2 anticipates working at an intensive outpatient treatment center for women with

eating disorders and substance abuse issues. The group described in this assignment could

definitely be conducted at this place of employment since that is a primary focus of the treatment

that is offered there. The treatment center accepts women over the age of 18 and since it is

located in a “college town” it would be practical for this group to be conducted there.

Student 3 anticipates and has set the goal to work as a counselor in a school setting where

he also hopes to coach hockey. Since Student 3 will be a counselor working with athletes, it

could be very practical for him to conduct this group in that setting. There would be some

modifications necessary since the students in his group would not be college students; but those

should be few.

Although the school counselor, the private practice counselor who works with young

girls, and the counselor at an outpatient treatment center for adult women work in different

settings; I believe it could be practical for this group or some very similar form of this group to b

conducted at all three places.

A potential obstacle in implementing the group we have developed for this assignment

could be that the very adults who are responsible for educating these collegiate female athletes

could put up invisibles barriers to them seeking treatment. Along with the ever present pressure

that the media puts on females to have that “perfect body,” coaches, parents, peers, and even fans

put pressure on these women to perform and to keep their bodies fit according to what is needed

to perform and not necessarily what is needed to keep them healthy. If a coach has a star player

and this player is key to the team’s and therefore the coach’s success, he/she may be less likely

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to teach that athlete about proper nutrition and will only teach them about nutrition that will

enhance their performance. The very fact that they are athletes makes it even more difficult for

them to adhere to treatment because of their drive to succeed in their chosen sport.

“A comparison of the psychological profiles of athletes and those with anorexia found

these factors in common: perfectionism, high self-expectations, competitiveness, hyperactivity,

repetitive exercise routines, compulsiveness, drive, tendency toward depression, body image

distortion, pre-occupation with dieting and weight.” (Bachner-Melman, Zohar, & Ebstein, 2006)

These women are receiving “boosts in self-image, feelings of self-worth, and sociability,”

(Abood & Black, 2000) by participating in sports and their fear of losing those things may keep

them from seeking treatment until their condition is critical.

It is important that the leaders of this group be self-aware regarding cross-cultural

interactions. They must be prepared to “deal constructively with prejudices, biases, and racist

elements in their lives that have either been passed on from a previous generation or learned

through isolated incidents and generalized.” (Gladding, Groups: A Counseling Specialty, 2012)

In general, the leaders of this group should educate themselves about any cultural issues which

may arise based (unknown, 2012) (United States Government, 2014) on the cultural backgrounds

of the members of this group and then they should conduct themselves in a professional and

ethical manner at all times to increase likelihood that this group treatment will be effective for

the group members.

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References

Abood, D., & Black, D. (2000). Health education prevention for eating disorders among college

female athletes. American Journal of Health Behavior , 24 (3), 209-219.

ANAD. (2014). Eating Disorders Statistics. Retrieved June 3, 2014, from National Association

of Anorexia and Associated Disorders (ANAD): www.anad.org/get-information/about-

eating-disorders/eating-disorders-statistics/

Bachner-Melman, R., Zohar, A., & Ebstein, R. (2006). How Anorexic-like are the Symptom and

Personality Profiles of Aesthetic Athletes? Medicine & Science in Sports & Exercise , 4,

628-636.

Castillo, D. T., Lacefield, K., Baca, J., Blankenship, A., & Qualls, C. (2014). Effectiveness of

Group-Delivered Cognitive Therapy and Treatment Length in Women Veterans with

PTSD. Behavioral Sciences , 2076-328X (4(1)), 31-41.

Collins, M. E. (1991). Body figure perceptions and preferences among pre-adolescent children.

International Journal of Eating Disorders , 199-208.

Crow, S. J., Swanson, S. A., Raymond, N. C., Specker, S., Eckert, E. D., & Mitchell, J. E.

(2009). Increased mortality in bulimia nervosa and other eating disorders. American

Journal of Psychiatry , 166, 1342-1346.

Foundations Family Nutrition. (2013). Foundations Family Nutrition. Retrieved June 19, 2014,

from Nutrition Counseling: foundationsnutrition.com/nutrition-counseling.php

Gladding, S. T. (2012). Groups: A Counseling Specialty. Upper Saddle River, NJ, United States

of America: Pearson Education, Inc.

Gladding, S. T. (2011). The Counseling Dictionary: Concise Definitions of Frequently Used

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Terms. Upper Saddle River, NJ, United States of America: Pearson Education, Inc.

Greenleaf, C. J. (2009). Female Collegiate Athletes: Prevalence of Eating Disorders and

Disordered Eating Behaviors. Journal of American College Health , 57 (5), 489.

International Association of Eating Disorders. (2014). IAEDP: Providing education and

certification/Promoting effective treatment. Retrieved June 20, 2014, from IAEDP:

www.iaedp.com

McCallum Place Eating Disorder Centers. (2014). McCallum Place Eating Disorder Centers.

Retrieved June 18, 2014, from McCallum Place Eating Disorder Treatment Programs:

www.mccallumplace.com

Petrie, T. A., Greenleaf, C., Reel, J. J., & Carter, J. E. (2009). An examination of psychosocial

correlates of eating disorders among female collegiate athletes. Research Quarterly for

Exercise and Sport , 80 (3), 621-32.

Summit Psychological Services, PA. (2014). Definitions. Retrieved 2014, from Summit

Psychological Services, P.A.: www.summitpsychologicalservices.

com/services/definitions

United States Government. (2014). United States Health and Safety. Retrieved 2014, from

Education: education.qld.gov.au/health-safety/promotion/drug-education/docs/pd-part-

f.pdf

unknown. (2012). Coat of Arms. Retrieved 2014, from SlowFamilyOnline:

www.slowfamilyonline.com/wordpress/wp-content/uploads/2012/09/COAT_OF_ARMS

_P.jpg.

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Attachment 1

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Attachment 2

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