"Ninety percent of all women overestimate their own body size"(Pipher, 1995, p. 3). This is the very thing that causes eating disorders to be on the rise in our country. Between five and ten million girls and women struggle with eating disorders, as well as one million men. The number of people with eating disorders and borderline conditions is triple the number of people living with AIDS. Eating disorders affect at least three times as many people as schizophrenia does. At least fifty thousand of the above mentioned will die as a result of their disorder Because of the secretiveness and shame associated with eating disorders, a lot of cases go unreported. Many of the facts surrounding these disorders are still not fully understood so treatment is slow and at times ineffective. Statistics tell us that approximately forty two percent of first through third grade girls want to be thinner, and eighty one percent of ten-year-olds are afraid of being fat. It is no wonder that women in our world today suffer from eating disorders with all of the pressures that are placed on them to be thin (www. Eating disorders and their precursors).

The term eating disorder is a very broad term, but broken down is "an extreme expression of a range of weight and food issues experienced by both men and women" (www. Eating disorders and their precursors). Bulimia nervosa is a more specific term used to describe a disorder in which a person binges or eats an excessive amount of food, usually high in calories, in a short time and then purges. The term nervosa reminds us that people suffering from bulimia are similar to those with anorexia nervosa in that both have a distorted body image and an intense fear of fat. They truly believe that a slender body figure is crucial to being accepted in the world.

Causes of Bulimia:

The question of cause has been around as long as the actual disease yet we still are not certain of what really causes these disorders of eating. Over the past fifty years, science has learned a great deal, but there is not a single consensus. Research continues to look into the causes of eating disorders. Many feel they are biological and are set off by genetic precursors. People with eating disorders must face long-standing psychological, interpersonal, and social conditions in overcoming their illness. Feelings of not being good enough, depression, anxiety, and loneliness as well as troubled family and personal relationships may contribute the development of eating disorders. Once started, eating disorders may become self-perpetuated Dieting, bingeing, and purging help some people cope with the painful emotions and give them a feeling of still being in control. However at the same time that they think they are in control these behaviors are undermining their physical health, self-esteem, and a sense of competence and control.

Warning Signs: Eating Disorders

• A marked increase or decrease in weight not related to a medical condition
• The developmental of abnormal eating habits such as severe dieting, preference for strange foods, withdrawn or ritualized behavior at mealtime, or secretive bingeing
• An intense preoccupation with weight or body image
• Compulsive or excessive exercising
• Self-induced vomiting, periods of fasting, or laxative, diet pill, or diuretic abuse
• Feelings of isolation, depression, or irritability.

Because eating disorders share a lot of the same criteria, the above list is a compilation of the warning signs that accompany any one of the eating disorders. One of these major disorders is bulimia nervosa. Bulimia is a relatively new disorder. Thirty or forty years ago a lot of people had not yet even recognized the disease or it's seriousness. Psychologists are now estimating the incidence rate for bulimia among college-aged women to be as high as one in every four or five. Acceding to the DSM-V, bulimia is diagnosed according to the following criteria (Pipher, 1995, p. 46).

Bulimia Diagnosis:

• Recurrent binge eating
• Eating that is abnormal and feels out of control
• Depression and self- deprecating thoughts following a binge
• Any three of the following five categories

Consumption of high calorie junk food during a binge

Hiding food and secretive eating

Termination of the binge by abdominal pain, sleep, or vomiting

Repeated weight loss and attempts to control weight by cathartics and diuretics

Weight fluctuations of over 10 pounds in one year (Pipher, 1995, 46).

How does this kind of a problem develop? That has been the question for years, and there are no pat answers. Among many clients a common trigger has been rejection by a man. This type of a rejection can prompt a search for the cause of rejection, and most women are lead to believe the problem lies in their bodies. There are other causes as well that can trigger the onset of a disease like this. In most cases women experience some type of failure and they attribute the failure to their own inadequacies. They also feel that one thing in their lives that they can control is their weight, so they use that to try to solve other areas that they feel they are failing at (Pipher, 1995, p.47-49).

Bulimia affects women in many different ways; these women become so obsessed with their bodies and weight that they lose all pleasure and enjoyment in life. They are no longer able to relax and enjoy things; they suffer from anhedonia, or an inability to experience pleasure. Bulimia is much like alcoholism; it is considered alcoholism's sister disease. Both of the diseases fit into the same type of cycle. (A) Woman loses control (B) She achieves satiety, and often sleeps off the effects of her binge. (C) The woman experiences remorse, along with a hangover. Both eating and drinking hangovers include headaches, bad breath, and queasiness. At this point the bulimic feel guilt and shame about their behavior. (D) The woman vows never to indulge again and feels a temporary optimism that she is back in control. (E) The stress of life begins to wear on her again, and she has no coping skills for diffusing the stress. She begins once again to look to bingeing to ease the stress. (F) She begins to rationalize for the upcoming bout. (G) Stops resisting and eventually gives into the binge and it repeat (Pipher, 1995, p.50).

Unlike alcoholism where the person can just walk away and vow never to take another drink, a bulimic can never do that; you cannot walk away from food and not eat again. Bulimics must learn to begin to see themselves for who they really are and begin to rationalize what is going on in their bodies. However one of the key factors in treating this disorder is to try to catch it early, it is very hard to treat after it has been developing for years. People suffering from this disorder often have a very hard time trusting therapists, previous relationships have turned out to be intrusive or controlling ( Kaplan, 99,p.2). This is where a group type of treatment can be very helpful to women trying to overcome, and repair themselves from this disease. It gives them an opportunity to see others suffering from the same thing they are and allows them to find some safety in building a relationship and becoming vulnerable.

The Group Design:

This group is designed specifically for women whoa are struggling with bulimia, but who want to change. It is a seven-week program to help you begin to see that you can indeed over come this and that it does not have to control you for the rest of your life. The design focuses on helping you to get rid of the distorted views you have of your body and food and to help you begin to look at yourself as a whole person, as well as to begin eating normally again.

*This group design is adapted from the program: You Can't Have Your Cake & Eat It Too: A program created for controlling bulimia.

Week 1: Education and Overview as well as getting aquainted.

One of the most important things that needs to begin developing in the first meeting is trust. Members need to feel as though they can trust one another. The next thing is that they can see that this program will work for them and that it will allow them to succeed and see results.

• Each group member is presented with a copy of You Can't Have Your Cake and Eat It Too which will serve as the workbook for this group.
• Start the group by allowing the members to introduce themselves and to share a little bit about why they are there. As well as why they feel that this program will be successful to them.
• The next step is to give them a brief overview of the problem of bulimia and some of the dangers that go along with it. Some of the members may not be entirely aware of what is going on in their bodies and how damaging it is, it is so important that they see exactly what this is doing to their bodies.
• Another area to be discussed is to give members a brief idea of statistics concerning this disorder, letting them know they are not alone and that this does not need to be kept a secret any longer.
• Clear goals need to be set up for the group as well as individual goals for each week.

Keeping a journal of what they eat, as well as a binge record for each week is very important.

• Close the meeting with assigning the homework section for this week in which they will answer some questions about calorie intake, and the frequency of binges. Refer back in the chapter and list of cop-outs that are given and which ones they feel apply to them.

Week 2: Eating as coping. Developing Alternative coping strategies.

• Open the meeting with a few minutes to allow members to talk and share about accomplishments they have made the previous week, or struggles they have had. Keeping it short to get on to the task at hand.
• The focus this week is to help the members see that there are other activities in life that can be enjoyed besides eating.
• Discuss the information presented in the workbook about the ideal weight for your build and height. This helps members to see that their ideas about ideal weight are not rational.
• Use the questions in the workbook to carryout on a discussion. Give them time to process how they indicate stress in their lives and then share with the group. Talk to them about setting goals in the area of communication, perception, and enhancement skills. They need to recognize and realize where they lack these skills and which ones will help them to help to deal with stress better.
• Ask them to take five minutes and write down what leads them to bingeing. Then have them share these with the group. This will help them to see what processes to avoid and things they can do to avoid getting to that point or situation.
• Homework: Read over the section in the workbook about confronting an overcoming binge, and have them keep track of the ones they used for next week. Continue to keep the bingeing and purging diary each day.
• The goal is that by this week they will have an idea of what seems to trigger their binges and also the thoughts and feelings that accompany this. By doing this they can then implement some of the coping strategies and what works for them.

Week 3: Self – Esteem, Perfectionism, and Depression.

• Allow time for sharing about the previous week's experiences.

• The focus this week is looking at what to do when you are unable to be who you think you need to be. The topic this week is looking at the idea of self-esteem, perfectionism, and depression. This is a very important week because as a lot of research suggests, many people who suffer with bulimia suffer from a perfectionist attitude. They feel as though they do not measure up.
• Have the members make a list of the "shoulds" in their lives. Listing things that they feel they should be to others, or that they should be able to accomplish. Now have them share them in the group, as stated in the workbook with the examples Most members will at least have some that are unrealistic and impossible to ever reach. After you have talked about them have them go back and put a U by those that they feel are unrealistic. Next have them go through and make a list of things that are titled I "want". Then have them discuss whether or not changing it from should to want makes them more likely to carry it out.
• Give them a few minutes to think about different ways that they can nourish themselves in other ways besides bingeing. Have them share suggestions and different things that they are currently trying. The purpose is to help them to see that they can get meaning out of life besides just in eating and that they can accomplish reasonable tasks.
• To wrap things up have them make a list of positive qualities that they see in themselves. Space for this is provided in the workbook so they can keep adding to it overtime.
• Homework: Have them continue adding to their list of the "I Should" nourishing activities, and positive qualities lists. Pick one thing from the list of nourishing activities and do it. Have them ask three different people who know them to tell them what they like about them. Continue the journal of bingeing and purging each day.

Week 4: Anger and Assertiveness

• Give them a chance to share what has been going on with them the last week, success or struggles.
• The focus of this week is to help them learn that they can express their feelings in an open, direct manner. Use some of the examples in the workbook page 54 to get things going and then ask them to identify some of their own experiences.
• Talk about the idea of stuffing it in, holding anger in or spitting it out, and blowing up. Then use the exercise in the book on page 55 which gives them the chance to write down an experience and identify who they were angry at, what they said exactly, and what did they wish they had said. In addition, listing the fears that held them back from saying what they really wanted to say.
• Stress to them the idea that they need to first calm themselves down and take a look at the situation and then go on to really share what is bothering them, in an assertive and constructive way.
• Homework: Review the material on assertiveness and human rights in the workbook. Note situations this week in which the individual felt angry and how she handles them. Record these. How did she feel she handled them? What changes did she make over the week? Continue the binge journal.

Week 5: Cultural Expectations of Thinness for Women.

• Allow time for discussion over experiences from the last week, both negative and positive.
• This week deals with the misconception of society that to be thin is to be ideal. Take some to time to allow the group to share about some of their feelings relating to this idea and to talk about possibly why they feel this way. If discussion does not flow quickly, share some of the samples mentioned in the workbook page64
• Next talk for a few minutes about the different stereotypes that men and women possess of each other. Then have them write down how they act around men and how they react around women. Most members will be surprised to see that their behavior is quite different even though they did not realize it.
• Homework: This week's homework concentrates on helping members to become comfortable with their bodies. They will set aside an hour in which you will be assured no interruptions and privacy. They will set up a full-length mirror and relax in a comfortable position. Spend the next hour or so looking at themselves and talking audibly saying that they like themselves. When they are done have them record what they liked about their bodies. Next find a magazine photo of someone's body that you think looks like yours, and one of someone who you wished you look like. Paste them on the page provided in your workbook and then ask your friends for feedback. You will get a much more realistic view of things after you have asked your friends. Continue your binge diary.

Week 6: Enhancing Body Image

• Give a chance for members to share experiences from the past week.
• This week focuses on the idea of enhancing what woman think and feel about our bodies. Many women torture themselves because they do not want to accept the growth and development of their bodies. Learning to accept our bodies even when they are not perfect (who's is) is this weeks focus. Last weeks goal focused on learning to discover and really look at their body and this week will use some of what was learned to further learn to like themselves.

• Talk about how thankful they can be because they have bodies that work, as well as the fact that overcoming bulimia will help them to be healthier and feel healthier.

• Take some time to talk about what it means to be comfortable with their bodies and learning to see their body realistically and without distortions. Taking some time to measure each other and compare it with measurements from people their height and frame size is also a good exercise.
• Another good exercise is to have the group make a list of the things they find sexy in a man. Members will be surprised to see how many of their choices have nothing to do with looks or body.
• Homework: First have them write down what they like about their appearance, what others like about it, and their "attractive behaviors". Next have them change something in their appearance aside from losing weight. Try a new hairstyle, new makeup, wearing jewelry, or anything else aside from weight. Have them record the reactions they received from others. Continue journal of bingeing.

Week 7:Summing up: Where are you now and where do you go from here?

• Allow them to share, because this is one of the last sessions allow them time to really talk and process what has gone on in their lives over the past six weeks.
• This is the point where it is really time for them to look and to take stock of their lives. They need to be honest about what changes they have made, but most importantly what still needs to be done to continue their road to recovery.
• Have them do some looking back to week one to see where they have come from. They need to recognize the positive changes they have been able to make. Now is the time that they need to look at their journal and recognize if there has been an overall change in their bingeing and purging since the start of the program.
• It is also important that they don't see this as an end to support just as a beginning and as a stepping stone. They may need to go through the program again or continue from time to time to meet with other members. Each person must take stock of what they still need to do for success.
• Continue using the book as a references to look back and see if they have overcome the feelings of worthlessness and apathy that they have been battling throughout the last few weeks.

Although this program can be a successful treatment for bulimia other treatment should at times be used along with this program. Bulimia as mentioned brings with it a large array of medical concerns as well and in extreme cases it is vital that those suffering seek out medical advice and attention as well as this form of treatment. One of the primary goals of overall treatment is to stabilize the patient's medical and nutritional status. This is the first step in resolving the psychological perceptions of the problem and to begin to see a need to reestablish healthy eating habits. Once these steps have been achieved it makes the group treatment more effective (Kirchner, 99, p.1).

References

Kaplan, A. (1999). Difficulties in treating patients with eating disorders: a review of patient and clinician variables. Canadian Journal of Psychiatry, 44, 1-10.

Katzam, M. (1986). You can't have your cake and eat it too: A program for controlling bulimia. California: R&E Publishers.

Kirchner, J. (1999). Treatments for patients with eating disorders. New England Journal of Medicine, 60, 1-2.

Pipher, Mary. (1995). Hunger Pains the modern woman's tragic quest for thinness. New York: Ballantine

Eating disorders and their precursors. http://www.edap.org/edinfo/stats2.html