VIEWPOINT

Can Eating Disorders Become Contagious in Group Therapy and Specialized Inpatient Care?
Walter Vandereycken*
Department of Psychology, Catholic University Leuven, Leuven, Belgium

Abstract Eating disorders belong to the broad category of self-harming behaviours which may be acquired in a social learning process of imitation, identication and competition. Hence, we should question the possible dangers or unwanted side-effects in treating patients together within a common therapeutic setting. But little is known about the frequency and extent of possibly negative inuences of treatment in a group format, the so-called risk of peer contagion in group therapy and/or inpatient treatment. We review in this paper the rather scarce literature on this subject in order to stimulate more critical thinking and systematic research. Copyright # 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

Keywords eating disorders; group therapy; inpatient treatment; peer contagion; social learning; imitation *Correspondence Walter Vandereycken, Liefdestraat 10, B-3300 Tienen, Belgium. Email: walter.vandereycken@ppw.kuleuven.be

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.1087

Introduction
Youth with deviant behaviour may carry the threat of contagion into the classroom, hospital or secure facility. No wonder a major concern is the paradoxical situation that peer inuence may adversely affect children and adolescents while attending programs meant to do just the opposite (Dodge, Dishion, & Lansford, 2006). In a clinical context, growing concerns about peer contagion have been raised with respect to suicidal behaviour and self-injury (Crouch & Wright, 2004; Dickens, 2010; Heilbron & Prinstein, 2008). Indirectly, eating disorders belong to the broad category of self-harming behaviours which may be acquired in a social learning process of imitation, identication and competition. However, it is difcult to study these processes because we have to rely on the patients cooperation just as in the case of denial of illness. Secrecy and concealment are common behaviours

in patients with eating disorders particularly in the beginning phase but also when they are in treatment. They pretend or fake having eaten, hide food, eat on their own, secretly purge, drink water before being weighed, distort or withhold information about their eating and purging, etc. (Vandereycken & Van Humbeeck, 2008). In the last decade, there is a rapidly growing interest in studying the impact of the media and the internet, especially concerning the so-called pro-ana websites. But similar and equally dangerous aspects of social learning during inpatient treatment or group therapy in eating disorder patients rarely have been taken into account in comparative studies, quality measurements or consumer satisfaction surveys with respect to specialized services or treatments. Beside anecdotal information and opinions of professionals in the eld, three types of studies about patients experiences in a therapeutic setting have been found: ethnographic

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reports by participant observers, qualitative investigations using mainly retrospective interviews and larger scale written surveys collecting patients opinions in a standardized manner. We will summarize this rather limited literature in the hope to stimulate more critical thinking on the part of the therapists and more systematic attention from researchers in the eld.

Subcultures in inpatient treatment

In 1981, a prestigious Dutch psychotherapeutic community (a residential setting for 65 neurotic adults) was faced with a kind of pseudo-contagiousness of eating and weight disturbances: Half of the women in the hospital were suffering from a disease which looked alike in that they were all too thin (varying from 20% below the normal weight to emaciated) and messed around with food. Never before had the similarities between so many patients been as visible and obvious to everybody (de Jong, 1983, pp. 221222). The tidal wave of anorexia-like patients had a great impact on the daily life of the entire therapeutic community, especially with respect to eating behaviours and mealtime habits. The label fragile was imputed by the whole community to the subgroup of thin patients: delicate patients who had to be weighed every week [. . .]. They gradually were spared to an extent that anyone might wish to be one of them! (p. 225). It took about a year before the staff realized something was going terribly wrong: We suddenly realized the extent to which the anorexic group was treating us instead of the other way around, and how the symptoms of a minority were used by the rest of the patient population in what may be called a resistance culture. A confrontation culture, dealing with what the structure and handling of food and eating was meant to be, had been delicately transformed into its reverse (p. 227228). Finally, the staff succeeded in restoring the therapeutic climate: The process of sanctication of anorexic patients, which is possibly as disruptive to therapy goals as scape-goating, had been stopped (de Jong, 1983, p. 231). More than 20 years later, and without referring to the previous report, Jones (2005) described the struggle of an English therapeutic community with the increasing number of patients showing eating difculties, but staff appeared reluctant to note the change or to think of the impact it may have upon the treatment process (p. 195). Are we any further now in understanding the

dangers of treating patients together within a common therapeutic setting? The National Institute for Clinical Excellence guidelines for the management of eating disorders recommend outpatient treatment as a rst choice, with inpatient treatment only for those at serious physical risk. At the issue of these guidelines in 2004, Dean Jade (principle of the British National Centre for Eating Disorders) has made the following remark: But I ask myself if an eating disorder unit is the best place for an impressionable young girl to be. (. . .) As any inpatient will tell you, a specialist unit is the best place to learn how to be really, really good at anorexia. They also breed their own subculture. Some patients have reported bullying and intimidation by the hard-core cases. If they eat anything at all, theyre called fat cows (Rice, 2004). Referring to this quote, in a most interesting blog about the dark side of inpatient stays, the anonymous but astute blogger called greythinking lists six ways of how inpatient stays can make people sicker: exposure to the sickest of the sick, picking up other eating disorder symptoms, competition among patients, unhealthy modelling, negative attitude towards treatment and no life outside of the eating disorder. As for breed[ing] their own subculture. . .well, Ive always said that there is an eating disorder world. You make friends in treatment. After discharge, you keep up and talk about how everyone is doing. . .is so-and-so back in treatment? I heard so-and-so is doing really poorly. Because youve given up school or work to go into treatment, the most interesting things going on in your life are your therapy and nutrition appointments. Everyone talks to each other about their appointments. You send each other cards. You continue doing the same arts and crafts that you were doing inpatient. Everyones lives are still consumed by the eating disorder so no one is doing great. Its all very dysfunctional (Greythinking, 2009).

The patients experiences

Remarkably, these negative aspects of inpatient treatment or group therapy are rarely taken into account in quality measurements or consumer satisfaction surveys with respect to specialist eating disorders services or treatments (Bell, 2003; Clinton, 2001; Clinton, Bjorck, Sohlberg, & Norring, 2004; Doran & Smith, 2004; Kopec-Schrader, Marden, Rey, Touyz, & Beumont, 1993; le Grange & Gelman, 1998; Newton, Hartley, &

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Sturmey, 1993, Newton, Robinson, & Hartley, 1993; Rosenvinge & Klusmeier, 2000; Schneider, Korte, Lenz, Pfeiffer, Lemkuhl, & Salbach-Andrae, 2010; SwainCampbell, Surgenor, & Snell, 2001). In a review of qualitative studies about the treatment of anorexia nervosa published between 1990 and 2005, the following remark was made concerning group therapy: Individuals positions within a group may bring out the ambiguity that is attributed to group therapy, which is sometimes considered useful but also has some caveats. Being together with people who also have anorexia nervosa may be benecial in the sense of promoting support, but it may also entail a series of negative effects that result in increased stress, e.g., patients may compete for thinness. Being together with other participants can also mean learning new bad habits concerning eating disorders, which may make patients feel even worse at times (Espndola & Blay, 2009, p. 44). In a large Dutch study of patients perceptions, treatment in a specialized centre was evaluated most often as helpful; when it was considered unhelpful, one of the factors participants mentioned was rivalry with other eating disorder patients on the ward (de la Rie et al., 2006). Anorexic patients treated in a Norvegian specialized centre for eating disorders were interviewed concerning their experiences with a special therapeutic program of adapted physical activity (Duesund & Skarderud, 2003). As to the question of whether treatment in a group with fellow patients would be preferable, the opinions were divided. Half of them thought that being the only anorexic patients would limit the chance to compete with and compare oneself to others. For the other half, being in a group was viewed as enabling them to support each other in the work of getting well. In the UK, Tierney (2008) interviewed 10 adolescents about their treatment experiences. Although being treated with others who had anorexia nervosa was found to have its advantages, it was also said to be difcult when a competitive element was present (to eat the least or to have the lowest weight). The arrival on a treatment unit of a new patient was described as arousing unwanted memories, stirring up a desire to return to their emaciated state, or resulting in a fear that the newcomer would think they were greedy for eating full meals. In another British study, using semistructured interviews with 19 anorexia nervosa patients who were treated in an inpatient unit, participants were asked how they felt about being with others in the same

situation as themselves (Colton & Pistrang, 2004). The participants experienced much understanding and support (emotional and practical) from fellow patients and found the friendships and sharing of experiences to be highly positive. But they also described distress due to the tendency of comparison and competition (like whos the best anorexic). Moreover, they admitted that being with fellow patients also meant learning bad habits not only concerning eating behaviour but other behaviours such as self-injury. Being confronted with others in a distressed state caused fear and upset. These positive and negative experiences were linked to the patients ambivalence towards giving up their anorexia (my friend or my enemy). Clearly, to live in close contact with fellow patients elicits mixed feelings and is viewed as both helpful and detrimental. This raises the question of whether extremely unwell patients should be separated from those closer to recovery and discharge. Such a solution, however, might deny those who are very unwell the opportunity of being helped by, and gaining motivation from those further along the recovery process (Colton & Pistrang, 2004, p. 314). Similar ndings have been reported by Offord, Turner and Cooper (2006): being alongside peers with anorexia nervosa was found helpful in terms of identication and support, and unhelpful in terms of comparison and competition. This study suggests, however, that these issues may be related to a patients stage of treatment with comparisons at later stages helpful in reecting on ones progress (Offord et al., 2006, p. 385). To understand the inpatient peer culture of adolescent girls with anorexia nervosa, Ferraro (2009) interviewed 5 current and 10 previous inpatients. About 40% of the participants reported a generally negative experience, 33% an overall positive impression and the remaining 27% had mixed feelings about peer group inuences on the adolescent ward. The experiences could be thematized in several polarities resulting in ambivalent reactions: belonging (connection, acceptance) versus individuation (isolation, shame); competition (sickness) versus self-focus (wellness); and safety (support, trust) versus fear (power struggles).

The cons of group treatment

We have mentioned the problems of an anorexic subculture in therapeutic communities, leading De Jong (1983) to the conclusion that these patients should

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be dealt with like the average patient. But the same year, across the Atlantic, Piazza, Carni, Kelly and Plante (1983) decided to start with specic group therapy when they realized the tendency among eating disorder patients to form subgroups on the psychosomatic unit of a childrens hospital. While such clustering had the benet of drawing some of the more isolated patients into a situation of mutual support and socialization, the negative aspects of subgrouping could be seen in their exchanging information about how much weight they had lost, which doctor set weight goals the lowest, and how many nutritive supplements they must take. Sometimes they would share clothes and hairdryers and sometimes calorie counters and laxatives and tricks of the trade, like hiding pennies in their socks before getting weighed or vomiting together in the bathroom (p. 276). The formal group treatment was a means to restructure the informal interactions in such a way that therapeutic aspects were maximized while countertherapeutic inuences were reduced (Piazza et al., 1983). In the following decades a lot has been published about group therapy in eating disorders (for review, see Harper-Giuffre & MacKenzie, 1992; Mcgilley, 2006; Moreno, 1994; Polivy & Federoff, 1997). Among the most important therapeutic factors operating in groups, Harper-Giuffre & MacKenzie (1992) described supportive factors such as the sense of commonality and universality (acceptance by peers with the understanding that ones experience is not unique), and learning from others by modelling and vicarious learning. Strikingly enough, they put all this in a positive perspective and pay little attention to negative interactions and pitfalls. Discussing common misconceptions and anticipatory fears about group therapy, the authors noted: Most new group members fear that the group will become a forced confessional and that they get worse by being with other patients. This idea of mental contagion and loss of control is particularly common (Harper-Giuffre & MacKenzie, 1992, p. 34). Elsewhere, these authors warned the group therapists to be alert that the members do not collude in resistant manoeuvres, but they felt condent that the advantages of homogeneity outweigh the potential disadvantages. In their view, the risks appear to be small and they advocated the group environment as a powerful format for promoting a sense of personal empowerment (Harper-Giuffre, MacKenzie, & Sivitilli, 1992, p. 108). Other advocates of group therapy are more cautious and warn future

clients: One unfortunate consequence of some groups is that the members may want to talk about new ways of purging rather than to learn other ways to cope with their feelings and problems. If you nd that the main topic in the group is a comparison of the most effective vomiting techniques, this is clearly the wrong group for you. A good group will encourage you to decrease your binging and purging, not teach you new ways to promote your bad habits (Weiss, Katzman, & Wolchik, 1992, p. 102; see also Chiodo & Latimer, 1983). Linked to the sense of belonging and connectedness in being treated together with fellow patients, there is the risk of reinforcement of a pseudo-identity, including the development of a pseudo eating disorder (Silber, 1987). Especially inpatient settings may face this problem. Being together for such a long time between group sessions may also allow the development of a separate group identity in which no therapists or authority gures are present. This has the potential to be a hindrance to therapeutic progress, as the patients may overidentify with having an eating disorder (Duncan & Kennedy, 1992, p. 154). In her ethnographic eldwork, involving a variety of treatment settings, Australian researcher Warin (2005) remarked that patients laughed about how they had tricked the staff through tactics [such as] hiding food in the ceiling panels, draining apple juice into bed pans that were taken away and disposed of by the nurses, and spreading butter between newspaper sheets or duvet covers (p. 107). These tricks, just like the concealment of anorexic practices and pseudo-compliance with treatment, can be related to the need to create status and power in situations where they feel constrained or out of control. It may also express their need to retain an anorexic identity. When treated together with fellow patients in a hospital unit, especially during mealtimes and weighing rituals, through competiveness and struggling for hierarchical positions within the group, it even becomes the need to be the best or most successful anorexic (Ison & Kent, 2010; Rich, 2006).

Treatment culture and subculture

Using anthropological concepts of relatedness, Warin (2006) remarked that anorexia nervosa is often described with negative connotations of sociality such as withdrawal, regression and intrafamilial conicts.

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Anorexic patients seem to negate practices that are taken for granted as creating and sustaining relatedness, from the everyday practices of commensality to the capacity to have children. But, on the other hand, they create new meanings and experiences of being related. According to Warin (2006), the disorder itself takes patients out of their normal circle of friends and family, and into secretive groups ruled by their own practices, language and hierarchy. Specic examples of this peculiar joining through a shared diagnosis or identity are the pro-anorexia websites, self-help groups and specialized inpatient treatments for eating disorders. In her ethnographic eldwork as a participant observer in a variety of treatment settings, Warin (2005) noticed that many inpatient programs effectively reproduced and supported the many isolating practices that people with anorexia use to negate relatedness (p. 108). Admitted to the hospital, soon patients transformed their rooms in such a way that they replicated the intimacy of their bedrooms at home. When patients join together in treatment settings they form highly secretive cults or clubs with others who share their diagnosis (Warin, 2006). These subcultures convey a feeling of connection and belonging to these patients. The binding component is the seductiveness of anorexia and the secrecy around it, but also the competitiveness. Refering to labelling theory and social constructivism, Vogler (1993) sharply criticized the eating disorders clinic for using diagnostic stereotypes as a means of social control. Especially in programs following the principles of the 12 steps put forward by Alcoholic Anonymous and copied by Overeaters Anonymous the therapist or stafs expecting patients to assume the identity of eating-disordered. This form of self-stigmatization, according to Vogler (1993), is the rst step in an identity transformation supposed to be necessary for recovery: patients can only get better if they rst admit to be sick and accept the personal weaknesses supposedly linked to their eating disorder. In a similar ethnographic study as a participant observer in an inpatient unit, Gremillion (2003) wondered whether the (frequently reported) anorexic experiences of isolation and competitiveness are amplied in this treatment setting (p. 20) and she suggested that the system itself could play into illness chronicity (p. 11). Bell (2006) goes even further by comparing the inpatient anorexic individual to a prisoner of the medical panopticon, continuously

observed and brought under control by means of treatment protocols that perpetuate the social disciplinary control over womens bodies via mainstream medicine (p. 283). These harsh criticisms remind us that therapeutic practices both reect and incorporate the process of social construction of an eating disorder (Hepworth, 1999). We should be aware of the various ways in which the eating disordered patient is constituted both in terms of the patients self-constructions and of the constructions by healthcare workers, including the tendency of stereotyping in negative portrayals of patients as being difcult, uncooperative, manipulative, untrustworthy, etc. (Malson, Finn, Treasure, Clarke, & Anderson, 2004). Closely linked to this issue is the danger of authoritative containment of patients within a rather coercive atmosphere of a hospital unit. The more a treatment is experienced as controlling and disciplining, with nurses mainly in a surveillance role, the higher the risk of a struggle for control, leading to rebellion in patients (Ramjan, 2004; Ryan, Malson, Clarke, Anderson, & Kohn, 2006). The patients perception of the therapeutic alliance is a crucial factor in the process of commitment to an inpatient treatment program (Gallop, Kennedy, & Stern, 1994; Wright, 2010). Inpatient treatment can get entangled in a complex web of interpersonal interactions between patients and staff, between patients themselves, and between different members of staff. So-called rebellious behaviours or treatment undermining tactics may in fact represent re-enactments of aspects in the patients history (Marsden & Knight-Evans, 2008). If the risk of anti-therapeutic subculture and behavioural contagiousness increases with the intensity and frequency of interpersonal contacts, then inpatient treatment (hospitals, residential settings and day treatment centres) may be viewed as the virulent breeding place one should avoid! Some experts believe one can manage contagion among inpatients through increased awareness, stricter rules and better communication (Murray, 2002). The risk is supposed to be greater in adolescents who are generally more impressionable, more attuned to peers and more competitive than adult patients, according to Craig Johnson: The best way to counteract such pro-anorexic behaviour is to move the culture of the ward from that of partners in illness to partners in recovery (Murray, 2002, p. 43). But, as we have reviewed, there is a serious lack of systematic research on this topic.

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Moreover, there exists such a wide variety of inpatient treatments that its negative side effects may vary just as much (Vandereycken, 2003). Probably it is a complex interaction between the therapeutic climate and the References
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