Counselling and Psychotherapy Research

ORIGINAL ARTICLE

Emotion-focused group therapy: Addressing self-criticism in the

treatment of eating disorders
Maggie A. Brennan, Michelle E. Emmerling & William J. Whelton*
Department of Educational Psychology, University of Alberta, Edmonton, Alberta, Canada

*Corresponding author. Email: wwhelton@ualberta.ca

Keywords: eating disorders, emotion-
focused therapy, group therapy, shame,
self-criticism, qualitative research
doi: 10.1002/capr.12012
Abstract
Aims: The purpose of this qualitative study was to explore the perspectives
of women with eating disorder diagnoses regarding their experiences of
participating in an emotion-focused therapy group treatment for eating
disorders. From the early sessions the group members chose to focus on self-
criticism, the issue they viewed as most salient. Methods: Data were col-
lected through participant feedback forms and letters the participants
wrote to their self-critical voices towards the end of treatment. Findings:
Thematic analysis revealed six broad themes: (a) struggling to separate from
the critic; (b) recognising the destructive impact of the critic; (c) recognis-
ing the protective function of the critic; (d) accessing and accepting previ-
ously avoided feelings; (e) accepting my needs; and (f) valuing the
group. Implications for counselling: There is a pressing need for new and
effective treatments for eating disorders. The described group therapy
shows promise in treating self-criticism in the context of eating disorders.

73% of individuals with anorexia nervosa, bulimia

Introduction
Eating disorders, particularly anorexia nervosa, are
the most lethal of all psychological disorders, accord-
ing to some estimates resulting in fatality rates close
to one in five for those affected (Cavanaugh & Lem-
berg, 1999). Eating disorders as a group are also
among the most chronic of psychological disorders,
having low rates of treatment success (e.g. Carter
et al., 2011; Wilson, Grilo, & Vitousek, 2007). Both
researchers and clinicians remain puzzled by how
adverse and intractable these disorders can be and we
have experienced great difficulty with these clients in
our practices. Despite their devastating social, physical
and psychological consequences, those affected gener-
ally resist efforts by family members or professionals
to change them. A review of treatment outcomes for
anorexia nervosa revealed that of those who survive
the early stages, 20% remain chronically ill and
approximately 63% relapse (Steinhausen, 2002).
Similarly, standard psychological treatments are inef-
fective for up to half of those with bulimia nervosa or
binge eating disorder receiving treatment (Wilson
et al., 2007). A major contributing factor is that 51–
nervosa, or eating disorder not otherwise specified
drop out of treatment (Fassino, Piero, Tomba, &
Abbate-Daga, 2009). This means that new treatments
are needed and this report will present preliminary
results from a promising group treatment approach.
The aetiology of eating disorders is complex and
multifaceted but in this paper we will focus on the
important role of emotional avoidance and regulation.
Eating disorder behaviours appear to play a functional
role in effectively allowing individuals to control
affect that is otherwise felt to be overwhelming and
intolerable especially anger, sadness and shame
(Dolhanty & Greenberg, 2007). Individuals with these
disorders experience a great degree of shame, which
may lead to the disordered behaviours and/or result
from these behaviours (Gilbert & Goss, 2002; Goss &
Allan, 2009). Shame is often deeply internalised and
harsh, annihilating self-criticism is one of the deepest
and most painful sources of feelings of shame (Whel-
ton & Greenberg, 2005). One component of lasting
and effective treatments of eating disorders for many
patients is the alleviation of their shame and self-
critical process.

Counselling and Psychotherapy Research, March 2015; 15(1): 67–75 © 2014 British Association for Counselling and Psychotherapy 67
Eating disorder group
This study describes a 12-week group therapy pro-
cess facilitated by the first two authors and supervised
by the third. All have been extensively trained in
emotion-focused therapy, which we will describe in
the next section of this paper. The therapy was limited
to 12 weeks and required a focus, which was allowed
to emerge from the group members themselves. What
was most salient, even urgent, for the group partici-
pants, was their experience of intense shame and self-
criticism, sometimes referred to as ‘my eating disorder
voice’. A major insight we came to as therapists
observing this group was that there is a liberating
power in working on self-criticism in the context of
group therapy. The group members identified with
each other’s shame-laced internal processes and
nurtured in each other the seeds of healthy anger and
a more assertive self.
Emotion-focused therapy
Emotion-focused therapy (EFT; Greenberg, Rice, &
Elliott, 1993) works directly with evoked emotion and
has been adapted for use with eating disorders (Dolh-
anty & Greenberg, 2007). According to the EFT
model, emotions are part of an adaptive meaning-
making system that is crucial to our survival and
wellbeing (Greenberg, 2002). Emotions provide us
with information about the environment, facilitate
decision-making, organise us for action, and facilitate
interpersonal interactions (Greenberg, 2002; Wnuk,
2011). However, emotions themselves are not always
adaptive or productive (Greenberg, 2002). EFT differ-
entiates between primary and secondary emotions, as
well as adaptive and maladaptive emotions (Green-
berg, 2002). Within the EFT model, inflexible
maladaptive schemes are referred to as core problems
or issues (e.g. feeling unlovable) and become a focus
of therapy (Greenberg, 2002).
Chair work in emotion-focused therapy
EFT has incorporated and substantially developed two
dialogical strategies from Gestalt therapy (Greenberg
et al., 1993). Both involve evoking and therapeuti-
cally dramatising internal conflicts between aspects of
the self or the self and significant others that are creat-
ing obstacles to healthy living. In two-chair dialogue
the conflict is between two parts of the self. There are
two types of two-chair interventions: self-critical splits
and self-interruptive splits. In a self-critical split, the
client enacts the hostile, demanding, critical voice and
the frightened or shamed part of the self that experi-
ences this endless litany of abuse. Conversely, during
68 Counselling and Psychotherapy Research, March 2015; 15(1): 67–75 © 2014 British Association for Counselling and Psychotherapy
M. A. Brennan et al.
a self-interruptive split, the client enacts the part of
her that interrupts the experiencing or expression of
emotion, and the blocked part of the self that is
unable to feel or express emotion (Greenberg et al.,
1993). In empty-chair work, the dialogue is between
the self and a meaningful and significant person from
one’s life, most often a parent, for whom one still has
very strong, unresolved feelings such as resentment.
A topic of considerable discussion in psychology
and philosophy in recent years is the nature and
structure of the self (c.f. Taylor, 1989) and no firm or
definitive conclusions have been reached. Therapeutic
interventions in EFT are based on the dialectical con-
structivist theory of the self (Greenberg et al., 1993)
but this theory is posited as hypothetical and open to
new findings. Within EFT the ‘experiencing’ self is the
totality of the self being demeaned and attacked by
the inner critic and which self-organises emotionally
in response to that criticism, often at first as weak,
bad, or shameful and later much more assertively.
Other modes and schools of therapy view these or
similar self-organisations or inner ‘voices’ in some-
what different ways and with different labels and may
conduct effective therapy in accordance with the
constructs and principles they posit.
The application of emotion-focused therapy to eating disorders
EFT has been adapted for eating disorders based on the
theory that these individuals have an impaired ability
‘to access, identify and be guided by healthy emotions’
(Dolhanty & Greenberg, 2009, p. 367). This is believed
to result in experiencing emotions as overwhelming,
developing an aversion to emotions, and relying on
the eating disorder to avoid feeling (Dolhanty &
Greenberg, 2009). Dolhanty and Greenberg (2007)
were the first to adapt EFT for use with the eating dis-
order population. In this model, the therapist and cli-
ent deal directly with both the client’s fear of emotion
and the client’s feared emotions, so as not to reinforce
the feared view of emotion (Dolhanty & Greenberg,
2007). The therapist adopts the role of an emotion
coach and encourages in-the-moment experiencing of
emotion during session, thus creating opportunity for
new ways of interacting with and managing emotions
and effectively challenging the client’s dysfunctional
patterns and beliefs (Dolhanty & Greenberg, 2007).
Group application of emotion-focused therapy to eating
disorders
As the use of EFT with the eating disorder population
gains speed, it has begun to be applied in a group
M. A. Brennan et al.
format. Group work has been established as a valu-
able therapeutic model for treating eating disorders
(Moreno, 1994). Group support and decreased social
isolation have been shown to help sustain behaviour-
al and attitudinal changes in the treatment of eating
disorders (McKisack & Waller, 1997; Riess, 2002).
Group psychotherapy offers several advantages,
including the instillation of hope, interpersonal learn-
ing, experiencing cohesiveness, and reducing the
sense that one is alone in one’s suffering (Yalom &
Leszcz, 2005). Furthermore, sharing feelings and
experiences with others who are like-minded reduces
shame (Bales, 1944).
Wnuk (2011) was the first to adapt EFT to a group
format to work with eating disorders. She developed a
group EFT treatment for women suffering from buli-
mia nervosa. She conducted a 16-week group with 12
women. Results from this group demonstrate that
participants experienced significant improvements in
their emotion regulation and processing abilities.
Aims
The present study explored the perceptions of six
women with an eating disorder diagnosis about their
experiences of participating in a 12-week emotion-
focused therapy group. The purpose of the group was
to help participants find the connections between
their eating disorder symptoms and feelings, facilitate
the development of increased self-awareness, and
teach the participants to relate to themselves and their
emotions in accepting, healthy ways. The aim of this
study was to provide an exploratory, descriptive
analysis of client perspectives on the process and out-
come of participating in an emotion-focused therapy
group for eating disorders with a particular focus on
self-criticism.
Methods
Participants
Ethical approval for this study was granted by the
University of Alberta’s Health Research Ethics Board.
Participants were recruited through the University of
Alberta and several Edmonton community agencies.
A total of six women participated in the study. Partici-
pants were screened to ensure that they were:
18 years-of-age or older; had received a formal diag-
nosis of an eating disorder; had reached a minimal
level of weight restoration (to ensure cognitive capac-
ity to consent to and participate in the study); and
were not exhibiting current suicidal ideation, drug or
Counselling and Psychotherapy Research, March 2015; 15(1): 67–75 © 2014 British Association for Counselling and Psychotherapy
Eating disorder group
alcohol abuse or dependence, or psychotic symptoms.
Participants were also required to receive authorisa-
tion to participate from a general practitioner.
The participants selected for the study ranged from
22 to 58 years of age. They were all Caucasian, single,
and had attained a minimum of an undergraduate
degree. Of these six women, two were suffering from
anorexia nervosa (AN) binge/purge subtype, one was
suffering from bulimia (BN) and three were suffering
from binge eating disorder (BED). All had been suffer-
ing for more than five years. All of the participants
provided informed consent for participation in the
study and were assessed to make sure that they were
ready to commence deeper emotional work.
Procedures
The format of the group was based on the format
described in Wnuk (2011). Participants attended an
initial information session, followed by 12 weekly
two-hour group sessions. The information session was
used to prepare the participants and provide psycho-
education about eating disorders, emotions, and the
relationship between the two. During the next 12
meetings, the focus was on experiential psychother-
apy. These weekly sessions began with a brief partici-
pant check-in and homework review. For homework
the participants completed several worksheets includ-
ing a ‘learn to feel’ handout (i.e. identifying emotions,
the accompanying body sensations, and underlying
needs), self-criticism summaries (i.e. identifying self-
criticisms and the resulting feelings and needs of the
experiencing self), and identifying the pros and cons
of one’s eating disorder. Following the homework
review, the group would conduct two major individ-
ual segments of EFT chair work (lasting approxi-
mately 30–40 minutes) and subsequent group
discussion (Wnuk, 2011). During the check-in the
facilitators looked for markers of unfinished business,
self-critical splits, or self-interruptive splits to identify
issues appropriate for chair work.
In week seven the group facilitators introduced a
new element to the process by asking group members
if they had anything they wanted to say directly to
the internal critic of the person doing the chair work
(if permission was given by the individual doing the
chair work). This addition to the group process was in
response to the observation that the majority of group
members struggled to acknowledge the impact their
own critics had on them but were able to access anger
or sadness in response to hearing another group
member’s self-critic. Furthermore, observing others’
reactions to her own self-critical voice allowed the
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Eating disorder group
individual in the chair to then better access her feel-
ings regarding her own critical voice.
Data collection procedures
Qualitative data were collected through the use of ses-
sion feedback forms and participant letters. After each
group meeting, participants completed feedback forms
containing open-ended questions about their perspec-
tives of and experiences in the group. As the focus of
the chair work done in therapy largely centred on
group members’ annihilating self-criticism, they were
asked to write letters to their self-critical or ‘eating dis-
order’ voices as a closing exercise that the participants
completed for homework. The purpose of these letters
was to explore and highlight the work that had been
completed by each participant during her individual
two-chair work. Participants completed these letters
between the 11th and 12th group meetings.
Data analysis
Participant letters and feedback forms were analysed
using thematic analysis (Braun & Clarke, 2006). This
method was chosen for its ability to ‘search across a
data set – be that a number of interviews or focus
groups, or a range of texts – to find repeated patterns
of meaning’ (p. 15). The system of analysis involves a
recursive process of moving back and forth between
the entire data set, the coded extracts of the data
being analysed, and the analysis of the data that are
being produced. Thematic analysis is a foundational
approach to qualitative research that has the advanta-
ges of flexibility, rigour and accessibility. It is not
intrinsically committed to any theoretical framework,
which made it especially suitable for this project
(Braun & Clarke, 2006). The themes that emerge from
this approach can be effectively used to conceptualise
the experiences and realities of the groups under
study, which was the aim of the present study.
Findings
Thematic analysis of participant letters and feedback
forms led to the identification of six themes related to
participants’ perspectives regarding the process and
outcome of the group.
Theme one: Struggling to separate from the critic
Five of the women described how completing the
self-critic two-chair work helped to separate out
their critic voice from their experiencing voice, the
70 Counselling and Psychotherapy Research, March 2015; 15(1): 67–75 © 2014 British Association for Counselling and Psychotherapy
M. A. Brennan et al.
internal voice which articulates their deepest feel-
ings. Prior to participation in the group, all the
participants only identified with their self-critical or
eating-disordered voice. However, the two-chair
interventions helped them to reconnect with their
experiencing selves. For example, one participant
stated:
I need to acknowledge a very important part of my
learning through the ED group: the very fact of
addressing a letter to you means that I am acknowl-
edging your existence. Yes, you exist as a distinct
entity with your own unique voice – inside my
head. You are part of my consciousness and mind –
and yet you are separate. At least, I have been
learning to separate your voice from my other
voices and layers of my identity. (Participant C)
Another participant also wrote about the separation
of these two parts of herself. She shared recognising
the influence of external sources on her self-talk. It
was through this recognition that she was able
to decide that she did not agree with her habitual
self-criticisms:
One of the most powerful things I’ve learned about
you is that your voice and harsh criticisms are not
something I have internally generated, but rather
are an amalgamation of external discourses from
influential individuals in my life and from popular
culture that I have internalised. In other words,
they come from sources outside me which you have
told me are more authoritative, more knowing than
me. But really?! Pop culture is more authoritative
and knowing about me than me?! I’m supposed to
be a size two? Losing a bit of weight to be healthier
is a good goal. But holding me accountable to some
unrealistic image of what a woman ‘should’ be is
not! (Participant A)
By attending to the critic voice and exploring its
impact through the chair work, these participants
were able to begin to assert their healthy needs and
develop a voice outside of the critic voice. This was a
very liberating feeling for all of the participants as
they had gained awareness that the critic voice is not
who they are, but a separate voice that they can speak
out against. As was described by one participant:
‘being able to separate out your [critic] voice from
mine even for moments at a time has allowed me to
finally see pieces of truth’ (Participant D). The separa-
tion of the self-critic and experiencing self is also
important because the increased awareness facilitates
a new way of relating with oneself. For example one
participant stated: ‘It shifted my thinking, it showed
M. A. Brennan et al.
me my feeling side clearer, it showed me my human-
ity, it helped me to be more self-forgiving and gentler
in my criticism’ (Participant E).
Theme two: Recognising the destructive impact of the
critic
With the separation of the critic from the experienc-
ing self, the participants were able to develop an
awareness of the negative impact their self-criticisms
had on them. All of the participants identified as being
highly self-critical, but most of them had little insight
into how these criticisms emotionally impacted them.
Five of the group participants commented on the
power of recognising and being able to articulate their
internal critical voice in an emotionally alive way.
One participant identified how her self-critic made it
hard to function:
Your criticism is often so extreme – you do not just
speak but nag, yell, sneer, and denounce, reducing
me to an amalgam of deep and incurable flaws, and
depriving me of any ability and will to acknowledge
and validate my worth. (Participant C)
Processing the emotions that are evoked in the two-
chair dialogue often results in a softening in the harsh
internal critic. As one participant reported, recognis-
ing the viciousness of her self-critic allowed her to
evaluate the validity of its words:
You have tried to convince me that your represen-
tation of events is ‘hard fact’ or ‘reality’ rather than
just one possible version of things. Your version has
been particularly unkind, vicious even. But as I’ve
talked with you I’ve begun to see your version
of things doesn’t always make sense – in fact, it
borders on nonsensical. (Participant A)
As is indicated by these participant responses, the
result of working with the different sides of the inter-
nal split, from the different chairs, is that it allows the
internal dialogue to become alive in an emotionally
evocative way making it harder to continue to agree
with the critical inner voice.
Theme three: Recognising the critic’s protective
function
While the group participants spoke about their
growing awareness of the negative impact of
their self-critics they also shared the recognition that
their self-critical voice serves a protective function.
For example, group participants commented on how
it helped them to cope with difficult emotions and
Counselling and Psychotherapy Research, March 2015; 15(1): 67–75 © 2014 British Association for Counselling and Psychotherapy
Eating disorder group
life circumstances. As one participant so eloquently
stated:
Despite all that you’ve taken from me, I’ve also
come to realise that at other points in my life, you
probably saved me. You gave me a voice when I lost
mine and allowed me to cope, albeit in a destructive
way, with extremely difficult situations. (Participant
D)
Becoming more aware of the protective function of
the internal critic was a very powerful and insightful
moment for some participants as they were often
completely unaware that their daily battle with food
might serve an emotional purpose. In making auto-
matic reactions conscious, the therapy process helped
clients to see some of the motivations behind their
eating disorder and generated a greater awareness of
its role in their lives.
Theme four: Accessing and accepting previously
avoided feelings
Initially, the women in the group had difficulty iden-
tifying, expressing, and accepting their emotional
reactions. The responses in the participants’ critic let-
ters demonstrate that the group facilitated the devel-
opment of emotional awareness and an ability to
allow the experience of difficult emotions that had
previously been unavailable. For example, one
woman stated:
I’m finally starting to be able to see how much you
have lied to me, and, although I am still very
uncomfortable with the idea of anger or expression
of anger in general, I must say that there have been
a few times over the past four months that I have
felt SO mad at you for deceiving me in so many
ways and for distorting my view of what life is and
can be. (Participant D)
Although accessing primary emotions may be very
uncomfortable at first, it can also be very empower-
ing. Learning to express and direct anger towards
others, such as the self-critic, instead of the self,
empowers the individual to have a voice outside of
the eating disorder:
Telling me I shouldn’t eat that chocolate bar
because it has no nutritional value and is only
harmful to my health is great. Telling me to eat it
because I’m useless and have no hope anyway, and
then telling me I’m useless and have no hope
because I ate it . . . well to that I can now say, ‘fuck
off.’ Your criticisms have created the conditions
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Eating disorder group
under which I have struggled, the constant ques-
tioning and hesitating, and then you have turned
the blame back on me by convincing me it is only
evidence of my lack. In this way, you have been
entirely counter-productive. And again, to that I
can now say, ‘FUCK OFF!’ (Participant A)
Theme five: Accepting my needs
As participants began to become more aware of
their emotions and to identify, label, and express
them, they were able to develop an awareness of
internal needs that had been avoided or unmet up
to this point. Identification and assertion of one’s
needs to the self-critic is an important part of the
process in EFT chair work. Often asserting one’s
needs became a negotiation process within group
members: an attempt to honour both the value
underlying a self-critical process, and the need that
had been blocked. As one participant stated, ‘I need
you to be kinder, less harsh – criticisms should be
in my best interest, for my best interest, and not
merely to bludgeon me for the sake of bludgeoning
me’ (Participant A). In their letters participants
identified needs necessary for their recovery. For
example:
Give me space, time, and opportunities to acknowl-
edge and validate who I am and what I have done,
even take pride in what I have achieved. I do need
this foundation of self-acceptance and balance. It
would strengthen my hope and confidence in
myself and empower me to keep trying, growing,
and living a fuller life. (Participant C)
The negotiation process is also evident in another
participant’s words:
I can still hear you right now laughing at me,
because even though my glorified view of anorexia
as success has shifted, I still feel compelled to follow
its rules. You’re saying, ‘What does it matter if your
view of it has shifted, if it’s not going to effect a
change in your behaviour?’ You need to realise that
it DOES matter. That just because the behaviours
haven’t magically disappeared my experience of
them is so much different in a way that will hope-
fully facilitate the process of wanting-to-want to let
them go. (Participant D)
This passage also highlights how the group process
respected the individuals’ stage of readiness by work-
ing within their zone of proximal development
(Vygotsky, 1978), while simultaneously pushing them
72 Counselling and Psychotherapy Research, March 2015; 15(1): 67–75 © 2014 British Association for Counselling and Psychotherapy
M. A. Brennan et al.
forward, enhancing their motivation and capacity for
change.
Theme six: Valuing the group
Adopting a group format in the application of the EFT
approach was well received by the group members.
It appeared to offer many benefits not available in
individual therapy. Furthermore, including mixed
eating disorder diagnoses was also positively received.
Despite their behaviour differences, all six participants
were able to relate to having a self-critical voice. One
participant highlighted how she had benefited by wit-
nessing the impact of the self-critic on the other group
members: ‘The people in the group have been such
mirrors for me. Just as separating the critic from
myself gave me perspective, so does seeing other
peoples’ critics and others’ fears and others’ desires’
(Participant B). Another participant shared a similar
sentiment, commenting on the value of being able to
observe another woman’s chair work: ‘There isn’t one
piece of chair work that I didn’t learn something from
about myself and my own situation’ (Participant A).
Discussion
This study was based on a 12-week group therapy pro-
cess involving six women with eating disorders. The
therapy, through the needs and desires of the partici-
pants, became structured around the two-chair dia-
logue developed in EFT for working with destructive
self-criticism. Participants completed feedback forms
following each group session and were asked to write
a letter to their inner critic towards the end of therapy.
The main focus of the therapy was the shame and
self-criticism of the participants. The written words of
the participants were eloquent testimony of their dif-
ficulties and their progress in this domain. They began
therapy completely fused and identified with their
inner critics, what they often called ‘my eating disor-
der voice’. This experience is consistent with existing
literature, which has demonstrated that individuals
with eating disorders are often highly self-critical, a
characteristic that works to maintain eating disorder
pathology (Fennig et al., 2008; Steiger, Goldstein,
Mongrain, & Van der Feen, 1990). The participants
described the immense struggle involved in attempt-
ing to separate from that largely self-destructive
perspective in order to claim for themselves, however
hesitantly, a feeling and assertive self. The first two
themes are about separating the self from the critic
and becoming aware of the destructive nature of
intensely hostile self-criticism (Greenberg et al.,
M. A. Brennan et al.
1993). The awareness of the experiencing self as sepa-
rate and different from the self-critic appears to be a
crucial step in helping women with eating disorders to
feel empowered to have a voice and an identity apart
from their eating disorder.
The third theme expresses the counterpoint to the
second, namely that within the self-criticism resides a
desire to protect the self. This may seem contradictory
but it is more accurately viewed as a reflection of the
tremendous complexity of self-criticism. Within the
task analysis of two-chair dialogue there is a consis-
tent finding that as the self-criticism begins to move
towards resolution, the standards and values underly-
ing the self-criticism, however harsh, and the fear of
failing to attain those standards, will emerge (Rice &
Greenberg, 1984). Gilbert and his colleagues have dis-
covered two factors within self-criticism: A corrective
self-criticism, which is mostly adaptive and oriented
toward self-improvement and a much more persecu-
tory form of self-attack, which at the extreme hates
and wants to obliterate the self (Gilbert, 2009). The
self-criticism of those with eating disorders contains a
large quantity of the latter, but these participants
recognise in it a frantic desire to cope and to protect
the self in circumstances perceived as unbearable.
A growing body of research is demonstrating the
difficulty women with eating disorders have with
emotional awareness, regulation, and expression (e.g.
Davies, Schmidt, Stahl, & Tchanturia, 2011). Wildes,
Ringham, and Marcus (2010), for example, found that
anorexic patients avoid their emotions and their study
provided initial support for a model demonstrating
that anorexic symptoms can serve to avoid aversive
emotional states. Emotion regulation has become a
central focus of studies in many areas of psychopa-
thology, including for example substance abuse (Flo-
res, 2006). Pioneers in the field of emotion regulation
have shown the significance of interactive emotion
regulation in infant development and the centrality of
these processes for attachment and the healthy devel-
opment of the self (Schore & Schore, 2008). The
fourth theme highlights the power of two-chair work
in helping clients with eating disorders access the pri-
mary emotions that they have been avoiding through
the use of eating disorder behaviours. One of the
emotions that poses a very real threat for individuals
with eating disorders is the recognition and expres-
sion of anger (Ioannou & Fox, 2009). The qualitative
data from this study attest to the fear the participants
had accepting, regulating and expressing their emo-
tions, particularly negative emotions such as anger
and sadness. The appearance of anger and sadness
during the chair work posed a real challenge to all of
Counselling and Psychotherapy Research, March 2015; 15(1): 67–75 © 2014 British Association for Counselling and Psychotherapy
Eating disorder group
the group members, but the group process eventually
elicited deep, genuine anger towards the inner critic
and sadness that they spoke to themselves in such a
harsh and critical manner. The ability to access and
express anger appears to be a crucial component in
eating disorder treatment as it allowed these women
the opportunity to direct their anger outwards instead
of internalising it and acting out through eating dis-
order behaviours. The awareness and expression of
anger is also crucial as it has special significance in
confronting and challenging the corrosive effects of
internalised shame (Gilbert, 2009; Greenberg, 2002).
The fifth theme highlights how the participants
became aware of the needs associated with their
primary emotions and began to express those needs.
Through the chair work participants were able to
become aware of and express their unmet needs to
the critic, particularly the need for the space to find
their voice again and for self-compassion. This finding
is significant because research has demonstrated that
self-compassion helps to counteract self-criticism and
facilitates greater regulation of internal experiences
(i.e. thoughts, emotions, sensations, Neff, 2003; Neff
& McGehee, 2010). Additionally, being able to assert
themselves in this way empowered their experiencing
voice.
The sixth theme expresses the importance of the
group process in the treatment of eating disorders.
Having all group members share that they valued the
group process and were able to gain insights from
each participant is important information for clini-
cians as it suggests that mixed diagnostic groups may
not be problematic when dealing with the emotional
components of the eating disorder instead of focusing
on the behaviours. Of most importance was the expe-
rience of being able to witness another group member
becoming aware of the power of her self-critic. Being
able to witness another member struggling to deal
with her own critic brought out primary emotions like
anger and sadness towards the others’ critics, allowing
the other group members awareness and insight into
their own anger and sadness towards their own self-
critics.
This study has several limitations. It is based on a
small sample of participants in one course of group
therapy that lasted for 12 sessions. No follow-up
measures were attempted. The findings need further
validation and replication over future studies.
Conclusion
This paper described a structured, 12-week EFT ther-
apy group for women diagnosed with various eating
73
Eating disorder group
disorders. EFT has begun to be used for individuals
with eating disorders but this group approach is a very
recent and largely untested development. The main
focus of the group work was on helping the women
confront, process and change their vast self-criticism
through the use of two-chair dialogues. A qualitative
analysis of their letters to their inner self-critics illus-
trates their growth and development in the ability to
foster a sense of self apart from the critic, separate
from and confront the criticism, listen to their feel-
ings, and act on their needs. The group process was
valued by participants because they were able to
vicariously process and support each other’s work on
self-criticism and this benefited them in their own
struggles. This group was well-received by participants
and is a promising approach to therapy for eating dis-
orders, one that incorporates many lessons from basic
research on emotions in this population. Given the
scarcity of therapy services for so many, a group
approach has the appeal of being more efficient and
economical as well.
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Biographies
Maggie A. Brennan is a Doctoral Candidate in the
Counselling Psychology programme at the University
of Alberta. She is interested in the use of mindfulness-
based practices to develop emotion regulation skills
and self-compassion. Maggie’s research is investi-
gating the use of mindful yoga in the treatment
of women with bulimia nervosa and binge eating
disorder.
Michelle E. Emmerling is a Registered Psycholo-
gist in the province of Alberta. Her dissertation
explored the integration of emotion, autobiographical
memory and narrative identity in anorexia nervosa.
Michelle’s clinical practice is based in Edmonton,
Alberta, where she works with individuals suffering
from eating disorders using an emotion-focused
approach.
William J. Whelton is an Associate Professor at
the University of Alberta. He completed his doctoral
degree at York University, where he trained with Les
Greenberg in emotion-focused therapy. One of Bill’s
many research interests is the role of emotion in
successful therapy.
75
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