International Journal of Group Psychotherapy
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: https://www.tandfonline.com/loi/ujgp20
Patients’ Experience of a Narrative Group Therapy
Approach Informed by the “Tree of Life” Model for
Individuals with Anorexia Nervosa
Jeyda Ibrahim & Kate Tchanturia
To cite this article: Jeyda Ibrahim & Kate Tchanturia (2018) Patients’ Experience of a
Narrative Group Therapy Approach Informed by the “Tree of Life” Model for Individuals
with Anorexia Nervosa, International Journal of Group Psychotherapy, 68:1, 80-91, DOI:
10.1080/00207284.2017.1315586
To link to this article: https://doi.org/10.1080/00207284.2017.1315586
Published online: 07 Jun 2017.
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International Journal of Group Psychotherapy, 68: 80–91, 2018
Copyright © The American Group Psychotherapy Association, Inc.
ISSN: 0020-7284 print/1943-2836 online
DOI: https://doi.org/10.1080/00207284.2017.1315586
BRIEF REPORT
Patients’ Experience of a Narrative Group
Therapy Approach Informed by the “Tree
of Life” Model for Individuals with
Anorexia Nervosa
JEYDA IBRAHIM, D.CLINPSY.
KATE TCHANTURIA, PH.D., D.CLIN., FAED, FBPS
ABSTRACT
The aim of this study was to develop and evaluate a pilot group using the Tree of Life
model for individuals with a diagnosis of anorexia nervosa. Qualitative feedback from
patients was collected in a focus group and analyzed using thematic analysis. Four
themes were identified: (1) an image to remember, share, and change, (2) constructing
an alternative perspective, (3) hope, and (4) creating a sense of community. The results
and their implications are discussed.
I
ndividuals with an eating disorder have expressed that the greatest
level of impairment they experience as a result of their illness is in
their social life (Tchanturia et al., 2012; Tchanturia et al., 2013).
Jeyda Ibrahim is a Psychologist in the Parenting and Child Team at Great Ormond Street
Hospital NHS Foundation Trust, and the National and Specialist Inpatient Adolescent Unit
(Woodland House) in South London and Maudsley NHS Foundation Trust. Kate Tchanturia is a
Reader in Psychology of Eating Disorders at King’s College London.
80
NARRATIVE GROUP THERAPY AND ANOREXIA NERVOSA
81
Finding the most appropriate group format to engage patients with an
eating disorder can be challenging. A recent review of group therapy
for individuals with eating disorders found that “communication,
sharing, and being with others” were the most valuable parts from
patients perspectives (Sparrow & Tchanturia, 2016).
The Tree of Life (ToL) is a creative therapeutic tool based on
narrative approaches (REPSSI, 2007). Different parts of a tree are
used as metaphors to represent different parts of an individual’s life.
For example, the trunk represents strengths and the branches represent hopes and dreams for the future, encouraging individuals to focus
on their strengths and to become more hopeful. The ToL tool was
initially developed to support children affected by HIV/AIDS in southern Africa (REPSSI, 2007). Since then, it has been used all over the
world in a variety of contexts (e.g., Hughes, 2013; Jamieson, 2012).
Research into group interventions informed by narrative therapy
with people with eating disorders is limited. One recent study in
Australia (Weber, Davis, & McPhie, 2014) reported the effectiveness
of a group using a narrative therapy framework with women who
reported both depression and an eating disorder. The group included
externalizing and personifying the illness, and strategies of how to
disengage from the eating disorder. To our knowledge, no previous
research has evaluated the use of the ToL model with patients with
eating disorders. The current pilot study aimed to explore patient
feedback about a pilot therapy group based on the ToL tool and
narrative therapy approach.
METHOD
Participants
Participants were females, aged 18–30 years, with a diagnosis of anorexia
nervosa, who were day patients at a specialist eating disorder service. Five
were approached to participate, and all had attended at least six ToL
group sessions. Of these, four took part in the focus group, and the one
who was unable to attend due to other commitments provided feedback
in written form (not included in the thematic analysis).
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IBRAHIM AND TCHANTURIA
Procedure
ToL approach. The ToL approach was adapted to form an eightsession group therapy intervention adapted for individuals with
anorexia nervosa. Table 1 shows a summary of each session, along
with associated difficulties and solutions, which were identified
through discussion between facilitators at the end of each session.
Each session was an hour long and had two facilitators: the first author
and an occupational therapist. The group aimed to support patients
to construct less problem-saturated narratives and externalize their
eating disorders; share stories and create a sense of community in
order to help each other create alternative stories; and reduce the
power imbalance between the clinical team and the patients.
A focus group was conducted after the ToL group. The aim of the
focus group was to promote a variety of responses from participants,
rather than derive a final conclusion with which everyone agreed
(Hennink, 2007).
ANALYSIS
Thematic analysis was used to analyze the data to explore both implicit
and explicit themes (Guest, MacQueen, & Namey, 2012). All participants provided written consent for use of information from the study.
Participants of the focus group were asked three questions: What did
you find most helpful about the group? What did you find least helpful
about the group? What would you like to change about the group?
The focus group was recorded and transcribed verbatim by the first
author (JI), who listened to the recording several times to become
familiar with the reflections before analyzing the data. The group then
read through the written transcript several times to establish themes.
Results
Four themes were identified as a result of the analysis: (1) an image to
remember, share, and change, (2) constructing an alternative perspective, (3) hope, and (4) creating a sense of community. Group
members did not comment on what they found least helpful or what
they would change about the group. Even when they were asked to
The Forest
(adapted
from
REPSSI,
2007)
Drawing the
Tree
(REPSSI,
2007)
Session Name
Description of Session
Difficulties and Solutions
To explore and remember our
Facilitators introduced the ToL tool and Different group members struggled with
identity outside the eating disorder
shared their own trees
different parts of the tree, some even
Each member was then asked to spend
struggled with drawing the tree as they
the session drawing their own tree
wanted it to be perfect
Using a group approach helped members
support each other and remind each other of
their strengths
Group members who had not completed their
tree in first session were asked to complete it;
some simply wrote out descriptions in the
shape of a tree rather than drawing one
To create a sense of community and During this session each member was
Some group members found it difficult
to share and be witnesses to each
asked to present a few parts of their tree
to accept the positive comments and
other’s strengths
The metaphor of a forest was used to
strengths other group members had
create a sense of community, and each
written about them
member was asked to write a note to
Group members were not asked to read the
every other member highlighting that
strengths others had written for them during
person’s strengths
this session; they were given a week to reflect
and asked during the following session
Aim of Session
Table 1. Summary of group sessions
NARRATIVE GROUP THERAPY AND ANOREXIA NERVOSA
83
Aim of Session
To share significant and anticipated
life events
To learn from each other’s coping
strategies through difficult life
events and prepare for future
storms
Description of Session
Difficulties and Solutions
During this session group members were Some group members struggled to
asked to explore significant life events
identify ways in which they had coped
they had experienced and how they
or gotten through a storm
had coped
Hearing other group members’ ways of coping
Group members were then asked to think
with difficult life events in the past gave ideas
about anticipated significant life events
to participants about how they could cope with
and how we could prepare for them
potential difficult life events in the future
Further, the concept of standing still like a tree
and waiting for the storm to pass was used
Externalizing To externalize the problem and to
Each member was asked to create their When we first started the group,
the Eating
think about its impact on ourselves
own metaphor for anorexia nervosa in
members felt concerned that the
Disorder
(the tree)
relation to the tree
group would include discussions about
(adapted
Discussion was then facilitated around
anorexia nervosa
from
how they thought anorexia nervosa
This session was used as a way of thinking
Morgan,
affected their tree and which parts of it
about anorexia nervosa, but as something
2000)
they could use to reduce the impact of
that happens to them rather than something
anorexia nervosa on themselves
that is a part of them
Our Optimal To continue building on resilience
The ToL metaphor was extended to
Some group members struggled with the
Self
and share ideas
thinking about what a tree needs to
idea of an “optimal self” as they felt this
(adapted
flourish (sun, water, and air)
meant a “perfect self”
from
Group members used each of these
A discussion was facilitated around “optimal
Ibrahim &
metaphors to represent different
self” being different from being”‘perfect”
Allen, in
things they could reach out to, to
The concept of optimal self represented
preparation)
support them in building resilience to
resilience as opposed to perfection
adversity (sun=activities/hobbies,
water=self-soothing strategies, and
air=resources/services)
The Storms
(adapted
from
REPSSI,
2007)
Session Name
Table 1. continued
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IBRAHIM AND TCHANTURIA
To support each other to re-frame
Each group member was asked for a
This was one of the most challenging
what were once thought of as
piece of creative writing before the
sessions as group members struggled to
weaknesses to strengths relating to
session about a specific difficult
share their stories
past difficult experiences
incident or period of time in their life With encouragement and each other’s support,
During the session they were then asked
group members were able to share their
to share this, and others were asked to
stories and listen to the strengths witnesses
identify strengths for them
identified for them— this then became one of
the most powerful sessions
Consolidating To explore how group members would Discussions were facilitated about how
At times, it could feel challenging for
(adapted
be able to use their trees and other
group members would be able to
group members to think about how
from
tools from the group in the future
maintain what they developed through
they would apply and utilize the
Ibrahim &
this group
metaphors in day-to-day life
Allen,
They were then asked to write a
Group members valued having a creative way
submitted)
motivational letter to themselves
to summarize the group and it was
summarizing their reflections on what
something they were able to take with them
they had gained and learned through
and read again in the future
the group
Reflecting on To provide a safe place for group
A non-directive focus group was
The focus group was facilitated by the
Our
members to be able to reflect on
facilitated for group members to have
group facilitators which may have
Journey
their experiences of the group
the opportunity to reflect on their
made group members hesitant to be
experiences of the group
honest about their feedback
Group members were also given an opportunity
to provide anonymous written feedback;
however, none took up this offer, and they
reported that they had been honest during
the focus group
Becoming a
“Witness’”
(adapted
from
Morgan,
2000)
NARRATIVE GROUP THERAPY AND ANOREXIA NERVOSA
85
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IBRAHIM AND TCHANTURIA
reflect on these explicitly, they expressed not being able to think of
anything and resorted back to reflecting on the positives of the group.
IDENTIFIED THEMES
Theme 1: An Image to Remember, Share, and Change
Three group members mentioned how valuable they found the creative side of the group. They felt that the visual and creative elements
(see Table 1 for details), and the metaphors used, would help them
remember what they had identified and learned.
Participant 2. I will definitely remember the tree of life because it is so visual . . . you can
keep it with you and you don’t need prompts to remind yourself.
Participant 1. I find words really difficult to describe my feelings . . . but pictures are so
much better.
Further, participants spoke about how they would be able to utilize
the tree in the future and how it provided scope for uncertainty and
change.
Participant 3. It is the kind of thing I would sit back in my old rocking chair and think,
“Did I achieve that?” and see how it changes over the years, and that’s ok because
branches do change.
Participant 3. Even though it has finished, it hasn’t finished because you can keep your
tree and go back to things and add things on it.
Theme 2: Constructing an Alternative Perspective
Three group members discussed how they had not thought about
things in this way before and how refreshing it had been to focus on
something other than the eating disorder.
Participant 4. I think it helped me challenge some of the misconceptions I had about
myself Participant 1. You’re like mapping your life and watching it grow.
They were able to link these new perspectives to their recovery in
general and integrate with other interventions they were receiving.
Participant 2. It challenged quite a few of our core beliefs because usual CBT, what I
have seen. . . can disrupt a behavior, but if you don’t have the self-confidence, it’s not very
sustainable.
NARRATIVE GROUP THERAPY AND ANOREXIA NERVOSA
87
Participant 2. I have become a bit more flexible because I have been a bit more confident
in myself, and it’s definitely the group that stands out for me the most in day care at the
moment
Participants also commented that this model offered them an
alternative perspective to their difficulties. Further, the opportunity
to practice doing this with other people’s narratives helped them to
internalize these skills so that they could also do this with
themselves.
Participant 2. Not only did you have people to help you find your own strengths but also
by practicing doing it with others, it means you could then redo it yourself in your mind
for other stuff, stories that you wrote.
Participant 4. The questions surrounding identity were, for me, particularly useful,
exploring my identity beyond the eating disorder . . . we are more than the sum of our
parts, we are more than our eating disorders.
Theme 3: Hope
Two group members discussed how it had previously been challenging
to think about the future. They spoke about feeling like “they were
setting themselves up to fail” if they set a goal or expressed a dream.
Participant 3. It’s quite nice thinking about how that could change over a longer period
of time rather than this is how it is now . . . and it gives you a bit of hope to think if things
have been like that before, why can’t they be like that again. Rather than it all being about
the dark path.
Participant 2. It has a positive drive to it, and I think that’s what made it so potent!
The concept of the branches representing hopes and dreams facilitated discussions around the concept of branches “falling off” and
“new ones growing,” which meant that hopes and dreams did not have
to be static or symbolize failure if they were not achieved. All participants were able to identify hopes and dreams during the group.
Theme 4: Creating a Sense of Community
All group members reflected on the experience of feeling more connected and supportive of each other, rather than in competition, which
was observed at times due to different meal plans. They were able to
share ideas and support each other to recognize their strengths.
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IBRAHIM AND TCHANTURIA
Participant 2. I felt it brought the group together. And I think that’s quite important in
day care to have that sort of cohesion of the group.
Participant 3. We were not forced to say anything, but the fact we sat around the table
felt like we still did it together, like we brainstormed together, so it felt like we were all on
the same boat, but we also wrote down our individual personal storms; I found that quite
comforting.
Further, all group members were able to share personal experiences during group, which indicated that they had been able to
form a good therapeutic alliance with the facilitators.
Informal Feedback
The group members talked about their ToL in their individual therapy sessions, which generated an interest in other clinicians, who
approached group facilitators to enquire more about the ToL group.
Further, one patient who was not in on the days the group was
running asked if she could have individual sessions using the model,
as she had heard such positive feedback from the other patients. One
participant took part in a ToL conference and talked about her
ongoing positive experiences of the ToL six months following the
group.
DISCUSSION
The group was designed using the ToL model as a tool to generate
strength-based narratives. Therapy with anorexia nervosa patients has
been documented as challenging, and the main reasons are social
anxiety and unhelpful thinking styles, such as cognitive inflexibility
and preference for concrete detail (for a large dataset, see Tchanturia
et al., 2012; for a systematic review, see Lang, Lopez, Stahl,
Tchanturia, & Treasure, 2014). Group members all reflected on the
visual and creative aspects of the group, which they thought made key
concepts easier to understand and communicate to others, and which
would aid their recall of the group contents in the future. Thus, it
seems that, through creativity, ToL approaches have the potential to
challenge the rigid, detailed-focused thinking styles that can be
observed in people with anorexia nervosa, making it easier for
patients to gain insight into the bigger picture.
NARRATIVE GROUP THERAPY AND ANOREXIA NERVOSA
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Treatment can often be challenging for patients with anorexia nervosa,
perhaps in part due to their low self-esteem. One of the aims of the ToL
group was to address low self-esteem by encouraging patients to remember
who they were outside of their eating disorder, and to support them and
help them support each other in constructing more strength-based narratives. Group members reflected on having more confidence in themselves
as a result of challenging negative thoughts and beliefs, and thinking
about themselves beyond their eating disorder. They reported that
being able to practice creating less problem-saturated narratives by witnessing and helping others do this helped them do it for themselves.
Group members spoke about the value of being able to recognize when
things had gone well. They described how the focus on strengths and
positivity in the group created a space for hopefulness. This suggests that
ToL groups might represent a method of implementing strength-based
psychology approaches in the treatment of anorexia nervosa.
Due to documented impairments in social functioning (Tchanturia
et al., 2013), and the fact that previous research has highlighted “communication, sharing, and being with others” as key elements of group interventions for people with eating disorders (Sparrow & Tchanturia, 2016),
other important aims of the group were to create a sense of community
and have group members support each other in developing positive
narratives. Further, it was hoped that the facilitators sharing their own
trees would reduce the power imbalance between themselves and the
group members, and create a secure base for therapeutic change to take
place. The theme of creating a sense of community that was identified in
this study is in line with previous research.
Limitations
This was a pilot group with a small sample size that contained only people
with a diagnosis of anorexia nervosa. It is therefore hard to generalize
findings, for example, to people with other eating disorders, men, different settings such as inpatient or community settings, and different age
ranges.
The focus group was facilitated by the same facilitators as the intervention it was designed to evaluate, which may have made it difficult for
patients to give negative feedback. To try and overcome this, group
members had the opportunity to give anonymous feedback; however,
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IBRAHIM AND TCHANTURIA
they did not utilize this opportunity. Further, the data was analyzed by
one of the facilitators who developed the group, which may have
increased the risk of bias in the interpretation of results. Future research
would need a larger sample size as well as external researchers to collect
and evaluate feedback to reduce the likelihood of any bias.
Implications
The group format of the ToL intervention was an important factor in
creating a shift from problem-saturated narratives to strength-focused
narratives. Group members were able to support each other in creating
alternative narratives. Although a patient’s low self-esteem can be challenging to shift during individual therapy, group therapy provides the opportunity for other group members to be witnesses to their story and identify
their strengths through the stories told. Group participants reported it was
helpful for them to be able to consider themselves differently and be
hopeful about the future. Future research should continue to use group
formats for the delivery of interventions as this helps individuals share
their stories, be understood, and develop improved self-esteem.
Given the known cognitive and executive functioning difficulties in
individuals with a diagnosis of anorexia nervosa (Lang, Lopez, Stahl,
Tchanturia, & Treasure, 2014; Tchanturia et al., 2012), it is not surprising
that group members mentioned how useful the visual and creative elements of the group had been. Clinicians might therefore wish to consider
using more creative and visual elements in their work with people with a
diagnosis of anorexia nervosa.
ACKNOWLEDGMENTS
The authors would like to acknowledge Jo Bynre (lead occupational
therapist) for co-facilitating the group and Dr. Jane Evans for providing
clinical supervision to JI during her clinical training. KT wants to acknowledge the Swiss Anorexia Foundation for support to develop group interventions for patients with anorexia nervosa. We are also very grateful to the
rest of the team who showed genuine interest in the group and the
patients who took part in the group and provided feedback. We would
finally like to acknowledge Dr. Jennifer House for supporting us with the
editing of this article.
NARRATIVE GROUP THERAPY AND ANOREXIA NERVOSA
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Kate Tchanturia, Ph.D., D.Clin., FAED, FBPS
Institute of Psychiatry, Psychology and Neurosciences
King’s College London
London SE5 8AF, UK
E-mail: kate.tchanturia@kcl.ac.uk