Dangerous Liaisons: Group Work for Adolescent Girls who have Anorexia Nervosa
Introduction
Anorexia nervosa is the third most prevalent chronic health condition for adolescent girls (Fisher, 2003). It appears to be diagnosed with increasing frequency (Lucas, Beard, O'Fallon, & Kurland, 1991), with diagnosis typically occurring during adolescence (Cooke & Sawyer, 2004). Anorexia has traditionally been considered as an issue of popular culture, bought about by the increasing expectations on women to align themselves with images from the media (Chernin, 1985). Disturbingly, some studies have detailed that weight concerns can emerge as early as the 5th Grade, with Stein & Reichert (1990) finding that 50% of 10 year olds had engaged in weight loss strategies. However there is no proven causal link between body image / weight concerns and a diagnosis of anorexia nervosa (Ricciardelli & McCabe, 2001). In fact, clinical experience suggests that many young women with anorexia are not fixated on the issue of thin-ness, but rather on an attempt to control some aspect of their environment ((this is also supported by a biographical text by Loewenthal, 1996). This tendency has been labelled Confirmed Negativity Condition by Claude-Pierre (1997), whose descriptions closely match the explanations offered by young women with whom the author has worked who frequently deny the influence of pop culture. Therefore a different construction of anorexia is as a mental illness, with genetic predisposition being indicated through twin studies (Lamberg, 2003). Co-morbid conditions frequently exist (Zraly & Swift, 1990) and misdiagnosis sometimes occurs due to common features with OCD, Schizophrenia and Depression (Rosen, 2003). The clinician's beliefs about the causes of anorexia have an important influence over their choice of intervention. Cognitive Behavioural Strategies, Family Therapy, Psycho-Education and Psychotherapy are all frequently discussed in the literature. However a sporadic picture is provided of what constitutes a successful intervention, particularly on the rare occasion that an adolescent population is specified (Bryant-Waugh & Bates, 1987).
If anorexia is constructed as a mental health disorder, it then seems inappropriate that those suffering are often treated in hospital settings because of the medical instability resulting from starvation. However, many group psychotherapy programs advise against accepting participants until they have completed active physical symptom management (Cramer-Azima, 1992). This is despite the fact that "very low weight is not found to be a contraindication to group treatment" (Hendren, Atkins, Sumner & Barber, 1987, p. 592). Clinical experience has shown that adolescents at the most acute extreme of the anorectic spectrum frequently receive sporadic psychological support that ceases at times of greatest need. For example, psychotherapy group programs for those with anorexia typically focus on developing a greater sense of personal autonomy and increased self-esteem (Bryant-Waugh & Bates, 1987). In direct contrast, it is common practice for hospital programs to restrict visitors, implement enforced bed-rest and enforce re-feeding programs in order to achieve weight gain and a return to physical health (Treasure, Todd & Szmukler, 1995). It is within this medical context, where understandings of group psychotherapy are varied, that fears regarding 'cross-contamination' are rife and dangerous liaisons are proposed (Murray, 2002).
It is true that people with anorexia often resort to secretive behaviours to direct attention away from their minimal food intake. Within the clinical setting where the author gained experience in this field,[1] it is common knowledge that the young people with anorexia frequently share strategies for hiding food and fooling staff regarding their eating behaviours. For this reason, patients are actively discouraged from interacting with one another. They sleep in different units on the ward and all social communication is supervised. This is in direct contrast with the therapeutic goals of many programs for this population, where social interaction is encouraged and personal isolation is addressed (Hendren et al., 1987). However, medical staffs do have evidence to support their doubts about the benefits of social interaction between young people with anorexia. The literature occasionally describes the dangers of inpatient admissions, where the behaviours of others serve as an influence and guide to the avoidance of food (Beaumont, Russell & Touyz, 1993). In addition, the competitive aspects of the disorder also cause concern, with anecdotal fears that women will strive to be thinner than their peers (Murray, 2002). Again drawing on the author's clinical experience, a number of young women have reported this to be true in a group work scenario. They noted their ambivalence in this setting to what professionals would consider positive achievements, such as the removal of a naso-gastric tube, or the achievement of sufficient weight to return home. Whilst few young patients would prefer to remain in the hospital environment, these achievements mark a terrifying progression away from strict personal controls over eating and are particularly highlighted by comparisons with others. Young women have described voices in their heads that comment on their increasing weight in comparison to others, emphasizing how their 'gain' has not been matched by their peers. These competitive thoughts are also acted out on a large number of websites that promote anorexic and bulimic behaviours (Andrist, 2003), giving medical staff good reason to fear the outcomes for their patients.
A Project on Music Therapy Group Work
Despite these characteristics of the disorder, there is a great deal of support for competently facilitated group work for those with anorexia nervosa (Cummins, 1996; Hendren et al., 1987; Rosenvinge, 2000), although no evidence from an Evidence Based Medicine perspective (BMJ, 2003). In addition to the many arguments that can be made for the benefits of group psychotherapy, the developmental stage of adolescence is often considered to lend itself towards peer-oriented work (MacLennan, 1994). The importance of peers in the experiments associated with identity formation has been well justified (Erikson, 1965). Given that the onset of anorexia often occurs during adolescence (Cooke & Sawyer, 2004), and that early intervention may be related to more positive outcomes (Strober, Freeman, & Morrell 1997), an argument can be made for exploring the benefit of group work for adolescents who have eating disorders.
In fact, the author[2] has made such an argument, and has been funded by the University of Melbourne (Early Career Researcher Scheme) to investigate the effect of participation in group music therapy for adolescents in the acute stage of anorexia nervosa. The objectives of the study are:
- To ensure that participation in creative group therapy does not result in negative outcomes
- To ascertain what benefits are perceived by the participants from involvement
- To establish a basis for a future control study that measures specific outcomes using standardised psychometric tools.
Group membership will consist of 6 - 8 adolescents who have previously been hospitalised for acute episodes of disordered eating and have engaged in the inpatient music therapy program. The group will run on a weekly basis for 20 sessions. Pre and Post Test measures of weight and Body Mass Index (BMI) will be taken and in-depth interviews will be undertaken post-participation with all the young people. Transcripts of the interviews will be analysed using grounded theory techniques and this information will be used to select the most appropriate tools for measurement in a further, evaluative study.
The music therapy literature provides many descriptions that suggest no harm will be done by such a project and that the benefits may be significant. In the literature reviewed, most authors employ a psychodynamic framework in explaining their work, with the exception of Hilliard who focuses on cognitive behavioural strategies (Hilliard, 2001). Authors describe work that focuses on fostering intra-psychic strength, linking different aspects of the self to be more whole, or connecting to the outer world in a more healthy way. Robarts (Robarts & Sloboda, 1994) focuses on the ability of music to enhance personal understanding, particularly in the process of individuation and developing a healthy sense of autonomy. Amongst other things, she theorises that it is the particular qualities of music that allow for a reconstruction of the self through active and creative participation (Robarts, 1994). The idea of interactive and creative expression is supported frequently, with improvisation featuring in most case studies. Nolan (1989) describes an improvisational approach that utilises music as a transitional object, bridging the inner world of the client with the outer world. He considers the improvisational framework to provide opportunities for challenging the client's cognitive distortions and experimenting with inter-personal behaviours. Trondalen (2003) also discusses the role of improvisational music making in enhancing connectedness, not only with the outer world but between the mind and the body. Her conclusions are enhanced through a phenomenological musical analysis of a client's improvisation that describes how this is represented musically. Smeijsters & Hurk (1993) also utilise a qualitative research approach to investigate work with a client who has symptoms of anorexia. Their work again focuses on the representation of the anorectic personality in their musical material, and suggests that identifying and expressing emotions is an important role for music therapy. Although the lack of evidence available from the music therapy literature is noteworthy, this is more reflective of the difficulties faced by all disciplines working in the eating disorder field. The study posed above seeks to gather information that may help to support future research that measures the benefit of participation, by asking those involved to indicate what aspects they felt were helpful and what may be investigated more thoroughly.
Although most of the music therapy literature describes working individually with clients, there is some reference to group work (Loth, 2003; Parente, 1989). In addition, the current author contacted some known music therapists to elicit their opinions on the topic of dangerous liaisons between young women with eating disorders in groups. Loth (personal communication, September 30th, 2003) emphasised the importance of group work to adolescents and noted the developmentally appropriate dynamics that occur within these settings - sibling rivalry, attachment and independence. Robarts (personal communication, September 17th, 2003) described group work as creating a theatre for personal and cultural change that does not exist in individual work. All those contacted (Loth, Robarts, Rolvsjord, Trondalen) felt that music therapy group work with this population was likely to be safe, if facilitated competently. This expert opinion played an important role in encouraging the development of the project and supporting an attempt to disprove the contagion effect that has been proposed.
Conclusion
Music therapists frequently work with clients for whom improvement is difficult to measure, or even to expect. Clients with multiple disabilities or dementia are not expected to recover and it is therefore difficult to provide 'evidence' of the benefits of music therapy work. In the field of eating disorders, there is very little evidence to support the long-term benefits of any intervention. In the author's clinical experience, music therapy does seem to offer something unique to young women who are suffering from acute anorexia nervosa. The use of song writing has been particularly effective in freeing patients to express themselves in a creative way that also articulates important aspects of their experience. The contribution of this material to the multi-disciplinary team has allowed a higher level of support and understanding to be facilitated between the young people and their medical support staff. It has also been a powerful medium for sharing difficult stories with family members and loved ones. Further research into the role of music therapy for those who have eating disorders will certainly be fruitful, and it may eventually provide the evidence that the medical world seeks. The study described aims to be a first, very small, step in that direction.
Notes
[1] The Centre for Adolescent Health, Royal Children's Hospital, Melbourne Australia.
[2] Thanks to Dr Jane Edwards who has acted as grant writing mentor to the author.
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