Improvements in Quality of Life and Readiness for Change After Participating in an Eating Disorder Psychoeducation Group: A Pilot Study

ABSTRACT

Psychoeducation groups are an integral part of eating disorder treatment in community programs, yet research on their efficacy remains limited. This study examines the impact of participating in a 10-week psychoeducation group on changes in quality of life and in readiness and motivation. Seventy-five adults who had eating disorders were included in the study. We administered the Eating Disorder Quality of Life Scale (EDQLS) and Readiness and Motivation Questionnaire (RMQ) before and after the group. After participation, respondents reported an 11-point increase in the EDQLS score and 9-, 8-, and 9-point increases, respectively, in the total action, confidence, and internality components of the RMQ score. In group exit evaluations, participants reported that the psychoeducation group improved their quality of life and their readiness and motivation to recover.

Introduction

Definition and Impact

Feeding and eating disorders, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), encompass seven disorders characterized by severe disturbances in eating behaviors and associated thoughts and emotions. They are anorexia nervosa (AN), bulimia nervosa (BN), other specified feeding and eating disorders (OSFED), binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), pica, and rumination disorder (American Psychiatric Association, 2013). Anorexia nervosa and bulimia nervosa are two of the most commonly recognized eating disorders (Campbell & Peebles, 2014; Mairs & Nicholls, 2016).

Anorexia nervosa is characterized by restrictive eating, resulting in insufficient nutritional intake and an inability to sustain a stable, healthy weight. It includes an intense fear of gaining weight, extreme efforts to control weight and shape, and a disturbance in the way in which one’s body weight or shape is experienced. There are two subtypes of AN, restricting type and binge-eating/purging type. Notably, AN has the highest mortality rate among psychiatric illnesses (Arcelus et al., 2011).

Bulimia nervosa is marked by recurrent episodes of binge eating. An episode of binge eating is characterized by eating, in a discrete period of time, an amount of food that is definitely larger than what most people would eat during a similar period of time, and lack of control over eating during that episode. Binge eating is followed by recurrent, inappropriate, compensatory behavior (i.e. purging) in order to prevent weight gain. Bulimia nervosa also involves being preoccupied with weight and body shape. People who have BN may not appear underweight and, therefore, their eating disorder may go unnoticed by people close to them.

OSFED is a category that describes eating disorders that do not meet the strict criteria for the other eating disorders. Examples include atypical anorexia, night-eating syndrome, and purging disorder (American Psychiatric Association, 2013). Despite a person’s initial symptoms and diagnosis, most people who have an eating disorder will experience diagnostic crossover (e.g., changing from AN diagnosis to BN diagnosis) at some point in their illness (Eddy et al., 2008; Milos et al., 2005).

Eating disorders (ED) are often intricately interconnected with sociocultural factors, including societal ideals of beauty, body image perceptions, and cultural norms surrounding food and eating (Culbert et al., 2015; Dane & Bhatia, 2023). However, the stereotyped pursuit of idealized body standards often overshadows the underlying struggles faced by many individuals battling eating disorders. These conditions extend far beyond food; they encompass profound psychological distress and medical disturbances, which impact perceptions of self-worth and quality of life (QoL) (Winkler et al., 2014) and in some cases can be life-threatening (Arcelus et al., 2011; van Hoeken & Hoek, 2020).

Eating disorders affect individuals irrespective of gender, age, racial and ethnic identity, sexual orientation, and socioeconomic background (Mangweth-Matzek et al., 2016; Nagata et al., 2020; Rodgers et al., 2018; Sangha et al., 2019). The prevalence of EDs has doubled globally, affecting approximately 8.4% of women and 2.2% of men (Galmiche et al., 2019; Santomauro et al., 2021; Wu et al., 2020). Factors such as globalization, industrialization, and urbanization have contributed to this rise, especially among non-Caucasian ethnic groups in North America and worldwide (Acle et al., 2021; Pike & Dunne, 2015; Pike et al., 2013). In some cases, this prevalence matches or exceeds that of non-Latino Whites (Marques et al., 2011). Eating disorders often go undetected, in particular, men who have EDs often face underdiagnosis, undertreatment, and misunderstanding by health-care providers (Austin et al., 2008; Currin et al., 2007; Strother et al., 2012). Even among those who have been diagnosed with an ED, studies show that life-time treatment specifically for an ED was reported by less than half (Fursland & Watson, 2014). There is an urgent need for effective evidence-based interventions to address these multifaceted challenges (Kazdin et al., 2017) as eating disorders significantly affect people’s health and QoL.

Quality of Life and Pretreatment Readiness and Motivation

Quality of life is significantly lower among individuals with EDs compared to those without, and even worse than patients with mood disorders. The reported impairment increases with the severity of ED symptoms (S. M. de la Rie et al., 2005; Jenkins et al., 2011; Keilen et al., 1994). Factors influencing one’s QoL extend beyond health. They include an individual’s sense of self and belonging, work or education, health and well-being, illness-specific psychopathology, life skills, leisure activities, sense of purpose, finances, living conditions, and even pets (S. de la Rie et al., 2007). While the primary focus of ED treatment may be symptom reduction, focusing on Qol can have a positive effect on individuals’ QoL and can be associated with significant improvements in ED behaviors and psychiatric symptoms (Bamford et al., 2015; Mason et al., 2017; Padierna et al., 2002; Williams & Reid, 2010).

Despite the profound toll on physical, mental, and psychosocial well-being, EDs are treatable through various therapeutic modalities (Keel & Brown, 2010; Keski-Rahkonen et al., 2007; Simic et al., 2022; Stewart et al., 2022; Treasure et al., 2020; Udo & Grilo, 2018). However, individuals with EDs often exhibit ambivalence toward change and may resist recovery due to perceived benefits and burdens associated with their disorder (Feld et al., 2001; Reid et al., 2008; Vitousek et al., 1998; Williams & Reid, 2010). Prochaska and DiClemente’s Transtheoretical Model highlights the importance of assessing individuals’ stage of change (precontemplation, contemplation, preparation, action, maintenance) and tailoring treatment accordingly (Prochaska & DiClemente, 1983). Pretreatment readiness and motivation for change are key predictors of treatment outcomes in EDs, influencing dropout rates, symptom change, and relapse occurences (Clausen et al., 2013; Geller et al., 2001, 2009; Vall & Wade, 2015).

Certain therapies, like motivation-focused therapy and Cognitive Behavioral Therapy (CBT), both individual and group-based, demonstrate the potential to enhance readiness for change (Ålgars et al., 2015; Allen et al., 2012; Feld et al., 2001; Geller et al., 2011). An individual’s willingness to continue with further intensive treatment may also be related to having experienced the therapeutic environment of treatment, peer influence, and a heightened sense of mastery associated with behavioral change (Guarda et al., 2007). Dropout rates from ED treatment and relapse are high, emphasizing the need for interventions that address individuals’ readiness and motivation for change (Bandini et al., 2006; Bewell & Carter, 2008; Dejong et al., 2012). It is important to tailor interventions that meet individuals at various stages of their treatment journeys (Bewell & Carter, 2008).

Group Psychoeducation

Group psychotherapy is a form of therapy in which one or more mental health practitioners deliver psychotherapy to several individuals together. In this setting, individuals with common diagnoses can participate in a safe, supportive, and cohesive space to address their shared concerns (Yalom & Leszcz, 2005). It is commonly offered as a treatment for EDs in community health-care settings and has been shown to be equally effective in the treatment of EDs as other common treatments, including individual psychotherapy, and more effective than waitlist control groups (Chen et al., 2003; Grenon et al., 2017; Tasca & Bone, 2007). This group-based approach is recognized for its therapeutic benefits in addressing social isolation, offering peer support and for its cost effectiveness (Nevonen & Broberg, 2005).

Group psychoeducation is a type of group psychotherapy that combines the elements of CBT, group therapy, and education. The goal is to provide the client knowledge about various facets of the illness, which can include a focus on symptoms, how it impacts the individual, and coping skills (Sarkhel et al., 2020; G. Waller et al., 2007). Research has shown that outpatient group psychoeducation for BN is associated with improvements in measures of psychopathology, including feelings of ineffectiveness, episodes of binging and purging, drive for thinness, and body dissatisfaction (Davis et al., 1997; Wolchik et al., 1986). Positive outcomes similar to those were observed in patients who have BED and eating disorder not otherwise specified (in the DSM-4 EDNOS was the category which has now been replaced by OSFED) (American Psychiatric Association, 1994) and have been documented in research on group psychoeducation (Balestrieri et al., 2013; Ciano et al., 2002; Clausen et al., 2013; Liquori et al., 2022). Additionally, group psychoeducation is associated with positive outcomes in the treatment of children, youth, and their caregivers (Geist et al., 2000; Holtkamp et al., 2005; Kurnik Mesarič et al., 2024; Spettigue et al., 2015). A few studies have shown that patients who participate in ED treatment (1–2 years in duration) report improvement in overall health-related QoL, but this QoL is still below the population norm (Muñoz et al., 2009; Padierna et al., 2002). The impact of short-term interventions, like group psychoeducation, on QoL remains unclear.

While group psychoeducation is associated with certain aspects of recovery, full recovery remains challenging, and relapse is common (Guarda, 2008; Keel & Brown, 2010; Linardon et al., 2017; Murray, 2019; Watson & Bulik, 2013). Participation in an introductory group psychoeducation program may be efficacious for patients as part of a stepped-care approach to eating disorder treatment (Dalle Grave et al., 2001) and may prepare them for additional recovery-focused treatment, especially when readiness and motivation increase. However, little is known about the impact of group psychoeducation in ED treatment on readiness and motivation.

Purpose of this Study

The purpose of this study was to measure the impact of group psychoeducation on QoL and on readiness and motivation to recover in people who have EDs. Thus, this study aims to address the following research questions:

1. What is the impact of completing a group psychoeducation program on quality of life in individuals who have an eating disorder?

2. What is the impact of completing a group psychoeducation program on readiness and motivation in individuals who have an eating disorder?

3. Which aspects of the group psychoeducation program do participants find most useful?

METHODS

Participant Recruitment

The setting for this study was a publicly funded, Canadian community-based eating disorders treatment program that treats children, youth, and adults who are diagnosed by their primary care practitioner (PCP) with AN, BN, or OSFED. To participate in the eating disorders treatment program, all clients had to be assessed and referred to the program by their PCP. In addition, clients were required to attend a 1-hour group information session (describing EDs and outlining the program and expectations) before being scheduled for an intake assessment. At the initial intake meeting, an ED clinician assessed these potential clients to confirm their eligibility for the program. The program eligibility criteria were that clients (a) must have been referred by their PCP with a diagnosis of AN, BN, or OSFED; (b) must have been followed by the PCP throughout the duration of their treatment; (c) must have been a resident of the city; and (d) the referral must have been accompanied by updated labwork. Exclusion criteria included alcohol or substance abuse being the primary presenting problem; acute psychiatric disorder that may account for the decreased food intake such as thought disorders (e.g. someone with schizophrenia who had delusions around food or major depression where decreased food intake was due to mood); and binge eating disorder (e.g., binge eating without any compensatory behavior).

Participants in the current study were recruited by an email invitation that was sent to all adult clients (at least 19 years old) who were registered for the psychoeducation group called Fundamentals during the February 2018 to March 2019 study period. The email contained a letter introducing the study and included the consent form. At the beginning of the first group session, the research assistant discussed the study and clients who were interested in participating signed the written consent form and completed the questionnaires.

Demographics

Seventy-five out of 80 (94%) eligible individuals consented to participate in the study. Approximately three-quarters were Caucasian with a mean age of 29.3 (Table 1). Most of the participants were female and their body mass index (BMI) at baseline was normal. The most common diagnoses reported were AN (43%) and BN (38%). Out of 75 participants, 54 (72%) completed both before and after Fundamentals surveys and were included in the analysis. Participants who were lost to follow-up (28%) were slightly younger and had a higher BMI than those who remained in the study, but these differences were not found to be statistically significant.

Table 1. Demographics and Baseline Characteristics of Study Sample

Characteristic	Total (N = 75)
Age, y, mean (SD)	29.3 (10.1)
Age at onset at disorder, y, mean (SD) (n = 68)	17.4 (5.6)
Gender, n (%) (n = 75)
Male	71 (94.7)
Female	2 (2.7)
Other	2 (2.7)
Ethnicity, n (%) (n = 75)
Caucasian	55 (73.3)
Caucasian and Asian*	8 (10.7)
Caucasian and Other*	5 (6.7)
Asian	5 (6.7)
Arab and West Asian*	2 (2.7)
Body mass index (kg/m2), mean, (SD) (n = 67)	21 (5.13)
Highest past weight (lb), mean, (SD) (n = 71)	154 (33.7)
Lowest adult weight (lb), mean, (SD) (n = 75)	108 (23.0)
Desired weight (lb), mean, (SD) (n = 70)	115 (16.9)
Self-reported primary eating disorder diagnosis, n (%) (n = 68):
Anorexia (includes atypical)	29 (42.6)
Bulimia	26 (38.2)
Other Specified Feeding and Eating Disorder	9 (13.2)
Binge Eating Disorder	2 (2.9)
Binge-Purge**	2 (2.9)
Past eating disorder treatment, n (%) (n = 75):
Yes	43 (57.3)
No	32 (42.7)
Substance use issues, n (%) (n = 74):
Yes	24 (32.4)
No	50 (67.6)

*Mixed heritage.

**Binge-Purge is not an official diagnosis in DSM-5.

Of the 21 participants who did not complete the after Fundamentals surveys, 15 participants dropped out of the program and six did not attend the last session and, therefore, did not complete the after Fundamentals surveys on the last day of group.

Sample Size

We initially aimed for a target sample size of 35 participants, considering it sufficient to achieve at least 80% power in detecting a mean one-unit change in EDQLS scores after the Fundamentals group. Power calculations utilized a standard deviation of two and a two-tailed significance level of 0.05. We were able to successfully recruit a total of 75 participants within the study period.

Psychoeducation Group/Intervention

“Fundamentals” is a 10-week closed (clients cannot join part way through the treatment) psychoeducation group, which all new adult clients in this outpatient program must attend. Each group session lasts 2 hours, with up to 16 participants and two clinicians. Fundamentals follows an explicit outline with standardized content and format that group leaders follow. There are two group leaders facilitating each group, who have a bachelor’s or master’s degree in counseling psychology, psychology, nursing, social work, or a related field and who have extensive experience providing ED treatment.

Each group session follows a standard format that consists of (a) welcome and icebreaker activity, (b) homework review, (c) didactic teaching, (d) group exercise, (e) learning new coping skill to add to the “toolbox” of coping strategies, (f) new homework assignment, (g) breathing/grounding exercise, (h) weekly charting—participants complete a short questionnaire reporting on their past week (Table 2; see the supplementary file for a detailed description of the weekly sessions).

Table 2. Fundamentals Group Weekly Outline

Week	Fundamentals Group Weekly Outline
1	How to make the most out of the group Icebreaker (done weekly at the beginning of the group) Discuss group guidelines and frequently asked questions Discuss “why groups” and “how to make the most out of the group” Toolbox: Describe concept of adding new coping skills to the “toolbox” Journal: Distribute blank journals Breathing/grounding exercise: Diaphragmatic breathing Charting (weekly self-report questionnaire to be completed and given to group leader at the end of the session)
2	Self-compassion and the “toolbox” of coping strategies Homework review (done weekly after icebreaker activity) Teaching: Introduce mind-body connection; recovery model; food, weight, and shape preoccupation as a symptom of other issues; self-compassion; health at every size concept Toolbox: Have participants think about helpful coping strategies and skills they learn throughout the sessions and write them down in their “toolbox” Breathing/grounding exercise: Grounding exercises Homework: Self-compassion break (Kristin Neff)
3	The recovery model and the “iceberg” metaphor (what is beneath food, weight, and shape preoccupation?) Teaching: Recovery journey (hope, self-responsibility, self-advocacy, support, meaning and purpose, awareness, personal vision); underlying issues that drive the ED (iceberg metaphor: What’s below the water line?) Discussion: What are you fighting for? Exercise: Brainstorm what might be above the water line (i.e., behaviors) and what might be below the water line (i.e., trauma, loss, unmet needs) Teaching: Ancel Keys’ Minnesota Starvation Experiment Breathing/grounding exercise: Square breathing Homework: Complete the Readiness Ruler (1–10 motivational rating) and journal on your motivation rating and on the connection between your ED behaviors and the issues “under the iceberg”
4	Stages of change and emotion avoidance Teaching: Recovery is a process; stages of change; emotional avoidance; “fat is not a feeling;” tuning into emotions Discussion: Thoughts and feelings about content presented Breathing/grounding exercise: Tactile grounding (hold an object and describe 3 details about it) Homework: When you “feel fat” or “feel out of control” ask yourself what might be going on. Journal.
5	The function of the eating disorder Teaching: Decisional balance grid Watch video about ambivalence and externalizing the ED and discuss Activity: Do decisional balance as a group (Benefits of the ED, cost of the ED, cost of recovery, benefit of recovery) Discussion: Review Recovery A–Z recovery story Breathing/grounding exercise: Using imagination to send your breath on a little journey around your body Homework: Journal about 2 components of recovery that you are willing to work on (based on Recovery A–Z)
6	How media influences our attitudes about body weight and shape Teaching: Myths the beauty industry wants people to believe; media; fad diets; how to combat the “fat talk” phenomenon Activity: Think of someone in your life that has positively impacted you and list 3 qualities about that person Breathing/grounding exercise: Mindful breathing Homework: Journal about 20 things you enjoy doing: for example, watching the sunset, playing with children, walking the dog, going for a drive, making soup
7	Triggers and automatic thoughts/thought distortions Teaching: CBT triangle (thoughts/behaviors/feelings) Exercise: Identifying individual triggers Watch video about automatic thoughts and thought distortions Discussion: How do we stop automatic thoughts/thought traps? Review automatic thoughts worksheet Breathing/grounding exercise: Breath counting Homework: Use your automatic thoughts worksheet and practice recording, rationalizing, and replacing.
8	Thought distortions and feelings Watch video on emotions and the brain Activity: Do an activity sheet on Feelings: True or False (i.e., Some emotions are wrong to feel). Discuss Teaching: What are feelings? Why do we have feelings? Breathing/grounding exercise: 54321 grounding exercise Homework: Draw a pie chart of your life, with each segment representing the degree to which you give attention. Draw another pie chart to show how you would like your life to look. What small step could you take to bring yourself closer to your ideal?
9	Feelings, urges, and behaviors Teaching: Primary emotions; feelings about feelings; urges and coping Activity: Review “Coping With Urges” activity sheet (which includes affirmations, delaying, distraction, self-care) Activity: Working on mandalas Breathing/grounding exercise: Pedaling with your feet Homework: Describe yourself at 80. Write a letter from you at 80 to you at your current age
10	Recovery Review content Review toolbox Discussion: Exploring your personal recovery hope Activity: Where are you in the recovery process and where would you like to be? Group exit evaluation

The goals of this program are to help participants develop insight into ED behaviors; facilitate connection between individuals who have EDs, which can help reduce isolation and shame; build upon participants’ abilities to improve well-being; and create a “toolbox” of coping skills. The groups consist of a combination of didactic teaching and therapeutic processing exercises wherein participants can share experiences and give and receive feedback.

Measures

Demographic Questions

Self-reported demographic data including age, gender, ethnicity, BMI, primary ED diagnosis, participation in past eating disorder treatment, and substance use issues were collected from the participants along with the first set of questionnaires prior to intervention (i.e., “before Fundamentals”).

Eating Disorder Quality of Life Survey (EDQLS)

The validated, 40-item, self-report questionnaire, EDQLS, reports excellent reliability and high construct validity (Adair et al., 2007). This instrument was licensed from the developer for use in this study. The EDQLS encompasses areas that reflect aspects of life that are impacted by EDs and are expected to improve during the course of recovery. It has demonstrated responsiveness to change across various geographical locations and clinical settings, even within a relatively short time frame, and is useful for evaluating ED treatment effectiveness (Adair et al., 2007, 2010). As opposed to just focusing on ED symptoms, the EDQLS consists of the following 12 domains. Sample questions are included in parentheses:

1. Education/vocation (e.g., The eating disorder has taken over my life)

2. Relationships with others (e.g., I turn down opportunities to go out with friends)

3. Emotional (e.g., I put myself down a lot)

4. Leisure (e.g., I have fun with others)

5. Cognitive (e.g., I have trouble concentrating)

6. Psychological (e.g., I show my true self to others)

7. Family and close relationships (e.g., I feel understood by someone in my family)

8. Future/outlook (e.g., I feel hopeful about the future)

9. Appearance (e.g., I’m constantly trying to fix my body)

10. Values and beliefs (e.g., I feel like nothing I ever do is quite good enough)

11. Physical (e.g., My sleep is restful)

12. Eating disorder (e.g., I skip meals on purpose)

High scores in these domains indicate higher perceived QoL in those areas. The internal consistency of the EDQLS was acceptable (Table 3).

Table 3. Cronbach’s Alpha Coefficients for Instruments Used

EDQLS	Cronbach’s alpha— Preintervention	Cronbach’s alpha— Postintervention
12 domains, 40 items	0.852	0.856
RMQ	Cronbach’s alpha - Preintervention	Cronbach’s alpha - Postintervention
Action	0.624	0.443
Confidence	0.578	0.556
Precontemplation	0.558	0.366
Internality	0.624	0.445

The Readiness and Motivation Questionnaire (RMQ)

This is a validated, symptom-specific measure of readiness and motivation for change in eating disorders. This instrument was used with permission from the developer. The RMQ measures total scores and readiness scores for precontemplation, action, internality, and confidence for each of the four eating disorder symptom domains (restriction, bingeing, cognitive, and compensatory behaviors). Menstruation, as a symptom, was excluded as part of analysis of the RMQ, as it is no longer a criterion for AN. The RMQ demonstrates good reliability and construct validity, and RMQ scores predicts anticipated difficulty of recovery activities, completion of recovery activities, decision to enroll in an intensive symptom-reduction program, and treatment dropout (Geller et al., 2013). Precontemplation scores reflect the extent to which individuals are thinking of making behavioral changes (e.g., How much of you has wanted to restrict your eating?). Action scores reflect the actual engagement or disengagement with ED behaviors (e.g., How much of you has been actively working to eat more?). Internality scores assess whether the motivation to change ED behaviors is due to self-driven reasons rather than due to external pressures (e.g., If you were to eat more [reduce your restricting], how much of this would be for you versus for others?). Confidence scores assess the extent to which individuals feel confident in their ability to change ED behavior (e.g., If you decided to eat more [reduce your restricting], how confident are you in your ability to do so?). Higher scores indicate higher motivation and confidence in their perceived ability to change their ED behaviors across four symptom domains. The internal consistency of the RMQ was moderate to acceptable (Table 3).

Group Exit Evaluation Survey

This survey (Appendix) consists of Likert-scale, multiple choice, and two open-ended questions. It was designed to capture participants’ experiences of the psychoeducation group, assessing overall satisfaction with the group, number of sessions attended, satisfaction with discussions and interactions, whether the group helped them to understand their eating disorder, components of the group that participants found most useful, impact on readiness and motivation to recover, and impact on QoL. The two open-ended questions asked were, “Do you feel that the Fundamentals group improved your readiness and motivation to recover? In what ways?” and, “Do you feel that the Fundamentals group improved your quality of life? In what ways?”

Procedure

Participants completed the Demographics Survey, EDQLS, and RMQ at the start of the first session of the Fundamentals group. To measure changes in the participants’ QoL and readiness and motivation to change, EDQLS and RMQ measures were administered again at the end of the last session of the 10-week Fundamentals group. At the end of the last session, participants also completed the group exit evaluation.

Group leaders were not present during the completion of the questionnaires to protect confidentiality and to reduce any potential influences on reporting. Participants were given a $10 gift card for their completion of the questionnaires at both time points. The study was approved by the University of British Columbia-Providence Health Care Research Ethics Board in Vancouver, British Columbia, Canada (Research Ethics Board # H17-02800).

Data Analysis

Descriptive statistics were summarized by reporting the mean (standard deviation) for continuous variables and the frequency (proportion) for categorical variables. Paired t-tests were used to compare the differences between before and after scores in EDQLS and RMQ for the Fundamentals group. The normality assumption was verified by visually examining the distribution of the paired differences for each question. The level of significance was set at p < .05 for all statistical analyzes, and all reported P-values reflect two-tailed tests. All analyses were done using R statistical programming (R, 2020).

Demographic information and responses to group exit evaluations were described using simple descriptive statistics (e.g., means and proportions). A sensitivity analysis was conducted to assess attrition bias by comparing the characteristics of participants who were lost to follow-up to those who completed the study.

Open-ended responses from the group exit evaluation were analyzed using reflexive thematic analysis (Braun & Clarke, 2012), which adopts a flexible approach in the interpretation of meaningful patterns in the data set. Reflexive thematic analysis emphasizes the researcher’s role in knowledge production and codes are understood to have contextual influences from researcher subjectivity in the interpretation of the qualitative data set (Byrne, 2022). Text analysis was done for open-ended responses to analyze word frequency by identifying most commonly occurring words using NVivo 12 software. Data were coded using broad, largely descriptive categories such as “forming connections to others with ED” and “developing coping skills” that captured common themes from the participant responses. The first and last author then reviewed the quotes and chose one that best represented each theme.

Missingness of Data

Missing values from partially completed surveys were handled in accordance with the scoring manual (Adair et al., 2007). For the EDQLS, any responses with four or more missing items from the total instrument were excluded. For the RMQ, symptom specific domains with missing values were dropped from final calculations for total readiness and motivation for change.

RESULTS

Quality of Life

After the Fundamentals group, participants reported an 11-point increase in the EDQLS score (95% confidence interval: 6.7–15.3; p < .01). Participants reported significant improvements in the after Fundamentals group in all domains of the EDQLS except for family and close relationships and physical health domains. Even in the domains of family and close relationships and physical health, there was a trend toward significant improvements; however, this did not reach statistical significance. When AN and BN subgroups were analyzed separately, there were also no differences in this QoL.

Readiness and Motivation

Participants reported higher total action (+9.19, p < .01), confidence (+7.75, p < .01), and internality scores (+8.74, p = .01) after the Fundamentals group (Table 4). Higher action scores indicate that participants were more likely to engage in healthier behavior change. Higher confidence scores indicate a greater degree of confidence in their ability to change their ED behaviors. Higher internality scores indicates that participants are more motivated to change their ED behaviors for themselves rather than for others. In addition, participants reported lower total precontemplation scores (−4.63, p = .05), which indicates higher readiness to change. Symptom-specific RMQ scores revealed that only the action scores increased across all four symptom domains consistently (Table 4); whereas, the changes in scores of other domains were varied (p > .05) and we cannot rule out random chance. When AN and BN subgroups were analyzed separately, there were also no differences in this readiness and motivation.

Table 4. Readiness and Motivation Scores Before and After Fundamentals

Total Readiness Scores	Before Fundamentals	After Fundamentals	P-value^†	Cohen’s D
Action	38.45 ± 19.7	47.64 ± 18.2	.001	0.316
Confidence	36.03 ± 17.4	43.78 ± 17.7	.003	0.395
Internality	60.31 ± 25.3	69.05 ± 21.6	.012	0.440
Precontemplation	70.69 ± 18.4	66.06 ± 17.5	.050	0.059
Symptom readiness score
Action
Binge	59.23 ± 40.0	66.32 ± 28.5	.011	0.189
Cognitive	38.27 ± 23.7	49.20 ± 26.0	.001	0.267
Compensatory	39.39 ± 24.0	47.06 ± 23.4	.071	0.261
Restriction	29.04 ± 29.3	34.52 ± 28.2	.047	0.043
Confidence
Binge	39.25 ± 28.5	43.95 ± 25.7	.395	0.152
Cognitive	22.71 ± 21.3	33.47 ± 21.3	.093	0.406
Compensatory	46.00 ± 23.6	52.35 ± 23.1	.358	0.278
Restriction	41.92 ± 28.2	45.00 ± 23.3	.268	0.120
Internality
Binge	76.5 ± 28.2	84.5 ± 22.9	.168	0.307
Cognitive	64.2 ± 28.9	71.7 ± 26.8	.444	0.231
Compensatory	59.4 ± 26.5	67.3 ± 28.6	.041	0.398
Restriction	45.9 ± 32.0	57.2 ± 30.7	.070	0.420
Precontemplation
Binge	61.50 ± 34.6	63.42 ± 32.1	.066	0.050
Cognitive	64.19 ± 29.0	58.27 ± 28.6	.111	0.115
Compensatory	71.53 ± 20.9	68.60 ± 20.1	.111	0.050
Restriction	80.77 ± 21.2	74.90 ± 23.3	.314	0.203

^†Paired t-test.

Group Exit Evaluation

Participants reported high satisfaction with the Fundamentals group (median: 4 [interquartile range (IQR): 4–5]). The average number of sessions attended was nine out of 10. It is important to highlight that group participants were discharged from the group if they had three “no shows.” Participants also reported high satisfaction with the amount of discussion/interaction (median: 4.5 [IQR:4–5]). Of the participants who completed the program, 96% reported that the group helped them to understand their ED better. Components of the Fundamentals group that participants found most useful were triggers and thought distortions, understanding underlying issues, and self-compassion (Figure 1).

Figure 1. Exit Evaluation – Responses to Question #5: Components of the Fundamentals Group That Were Most Useful, Ranked in Order of Frequency.

Eighty-five percent of the participants reported that the Fundamentals group improved their readiness and motivation to recover. Thematic analysis of free text responses related to this item revealed the following themes:

1. Forming connections to others with ED

 “[The group] gave me hope by seeing other people in my position. Helped me communicate anything to do with my ED more effectively. Made me feel like I had people to help with my recovery and I was not alone.”

2. Developing coping skills

 “[The group] helped to introduce some additional tools and coping mechanisms. [I realized the] importance of journaling and reaching out.”

3. Gaining understanding and awareness about the ED and recovery

 “[The group] has broken down the huge black unknown mass to me and now I know how to take some steps towards recovery.”

In addition, 75% of the participants reported that the Fundamentals group improved their QoL. Thematic analysis of free text responses related to this item revealed the following themes:

1. Symptom reduction

 “I have improved for the past 10 weeks. The skills I acquired have helped me to stop or at least challenge some of my ED behaviors.”

 “Less purging, more weight.”

2. Improved social support and connection

 “I learned the importance of connecting with others. Coming here has helped me get out of the house.”

3. Developing coping skills

 “I have concrete victories, coping methods, and a better understanding. I can cope with huge challenges in ways that shock even myself. I feel like a much stronger, mature person.”

DISCUSSION

This study found that after participating in the psychoeducation group program, Fundamentals, participants reported improvements in both QoL and readiness and motivation for change. This was further supported by participant comments in the exit evaluations, describing increased insight about the eating disorder, self-compassion, and coping skills.

The Fundamentals group content was based on evidence-based therapies including CBT (Fairburn et al., 2003; Linardon et al., 2017), Dialectical Behavior Therapy (Lenz et al., 2014; Linehan & Chen, 2005; Vogel et al., 2021), Motivational Interviewing (Macdonald et al., 2012; Miller & Rollnick, 2012), and Self-compassion (K. D. Neff, 2023; K. Neff & Germer, 2022). For example, there were three sessions in the Fundamentals group that focused on triggers, thoughts, feelings, urges, and behaviors. Teaching these concepts provides participants an opportunity to deconstruct how their triggers can quickly lead to ED behaviors, and by slowing down the process, they may be able to break the cycle by intervening with alternate thoughts and behaviors. This is highlighted by using the metaphor of the iceberg, as a reminder that there may be “more below the surface” than just the ED behaviors. This allows participants to have more self-compassion, be curious, and attempt to address the source of the triggers they may be experiencing, rather than just focusing on the behaviors. This is an important part of the recovery process as it can be empowering for people to grasp that their ED is understandable in the context of their broader life experience. They can learn about and experience ways that they can interrupt the cycle.

Participating in a structured group with clear guidelines may provide participants with a framework for treatment and a sense of accountability, as there are homework assignments that participants are invited to discuss at the beginning of the following session. These homework assignments and check-ins are not mandatory but are encouraged as they support the participant to reflect on recovery concepts and to practice skills between sessions. Ending with a breathing and mindfulness exercise promotes emotional awareness and self-regulation.

Our findings build on previous work but are new and original contributions of knowledge to this area of study. Much of the previous work on psychoeducation and eating disorders with adult populations has been focused on its efficacy in reducing eating disorder symptoms (Balestrieri et al., 2013, Ciano et al., 2002; Davis et al., 1990; Fursland et al., 2018; Liquori et al., 2022) and prevention (Celio et al., 2000; Zabinski et al., 2004). No previous psychoeducation studies have addressed QoL and readiness and motivation for change in eating disorder treatment.

After completion of the Fundamentals psychoeducation program, participants reported improved QoL; specifically, they scored higher in 10 out of the 12 domains of the EDQLS, including the domains of “Relationships with others,” “Leisure,” and “Emotional.” These findings are meaningful because individuals with EDs report significantly lower levels of health-related QoL compared to the general population (S. M. de la Rie et al., 2005; Winkler et al., 2014). Although improved QoL is a valuable outcome in itself, assisting clients to increase their QoL can be associated with significant improvements in ED behaviors and psychiatric symptoms (Williams & Reid, 2010).

The improvements that participants reported after the Fundamentals group may also be attributed to feeling supported in talking about the ED and exploring the functions of their ED in order to develop a deeper understanding of the role that it plays in their lives. Sharing experiences and receiving validation from other group participants and group leaders may help cultivate a connection to other group members and decrease isolation (Pettersen et al., 2011; A. Waller et al., 2020). Not only did participants report having greater compassion for themselves after completing the group, they also reported more hope that they could recover.

For some clients, group psychoeducation may be the only ED treatment that they receive; whereas for others, this treatment may serve as a stepping stone to further intensive outpatient, residential, or inpatient treatment. Therefore, having a positive experience in treatment can play a role in improving readiness and motivation for further treatment. Low motivation to change has been associated with more severe ED symptoms and body dissatisfaction and with higher treatment dropout (Geller et al., 2008; Vall & Wade, 2015; Zaitsoff & Taylor, 2009); whereas, higher levels of pretreatment motivation to change are associated with increased positive treatment outcomes in relation to restrictive eating behaviors, bingeing behaviors, and cognitive and affective measures of ED pathology (Clausen et al., 2013; Treasure & Schmidt, 2001). Higher levels of pretreatment motivation are also associated with higher remission rates in those with bulimia nervosa (Richard et al., 2005). Based on our findings, we would expect that the 10-week psychoeducation program prepares individuals with EDs for better outcomes after subsequent treatment. This expectation is supported by participant feedback from exit evaluations.

LIMITATIONS AND IMPLICATIONS FOR FUTURE RESEARCH

Limitations

There are several limitations in this study, each of which has a potential solution in a future study. First, the absence of a control group threatens internal validity because it is difficult to determine whether differences reported after the Fundamentals group are attributable to treatment alone. To determine a causal relationship between the psychoeducation group and subsequent improvements, future studies should include a control group, preferably through a randomized trial design.

A second limitation is that participants who voluntarily entered treatment were likely to have had higher baseline motivation to change or recover (self-referral bias). People who are able to participate in a 10-week program may have a higher level of executive functioning and better support systems (e.g., an employer who will give them time off from work to attend the group, families who will emotionally and practically support them). One potential solution for this limitation is to advertise the research study as part of a treatment program and pay individuals for participating.

A third limitation is that we were not able to properly interrogate group and leader effects due to the methodological constraints and small samples (see Supplementary Table S1). Future studies should use a systematic method for controlling for the leader effect, ideally with a larger sample size.

A fourth limitation is the predominantly Caucasian and female composition of the sample, which may limit the generalizability of results to other racial and gender groups. While participants from various ethnicities and genders were included, we did not have a large enough number to do any subanalyses. A potential solution to this limitation is to use a larger sample and/or purposive sampling according to ethnicity and gender, if feasible.

A fifth limitation is that approximately 30% of the participants did not finish the psychoeducation group. However, this dropout rate is consistent with that observed in other behavioral clinical trials (Berkman et al., 2006), and further analysis revealed no significant demographic or clinical differences between those who completed the study and those who did not. Thus, the incomplete information is not expected to significantly affect the findings of this study. To enhance participant retention and optimize outcomes, future research should focus on identifying and addressing the reasons for participant dropout.

A sixth limitation is that the absence of long term follow-up precludes an understanding of whether observed improvements are sustained. Future research should incorporate extended follow-up periods to evaluate the durability of changes over time.

Strengths of this pilot study include pragmatic design; use of validated, quantitative instruments; and analysis of exit evaluations.

Implications for Practice

The changes in QoL and readiness and motivation that we observed are not only beneficial in themselves but also support having group psychoeducation as a prelude to further therapy for EDs. This introductory treatment, assessed in its existing form without modifications, demonstrates its practicality and cost effectiveness as an important part of a person’s treatment trajectory.

Furthermore, this psychoeducation group process is easily learned and taught as there is a detailed weekly session outline, and new clinicians can be paired with experienced practitioners to deliver this treatment. The group not only accommodates participants at various stages of readiness to change, but also supports participants in examining their motivation and building strategies toward change. The content delivered in the psychoeducation group introduces new ideas and therapeutic models, which can be the foundation for additional therapy.

Although our findings are specific to the participants and studied setting, there is potential for extending the application of this intervention to diverse settings. Exploring its implementation in contexts such as postsecondary institutions, cultural communities, men’s programs, and substance-abuse treatment programs could broaden its reach, thus, this psychoeducation intervention may become more accessible to communities currently underserved by mainstream programs. Notably, the delivery of this psychoeducation group is adaptable, feasible both in person and through virtual platforms, enhancing its accessibility further.

In conclusion, our study affirmed the effectiveness of group psychoeducation as a valuable therapy for eating disorders. This structured, practical, and cost-effective treatment accommodates diverse readiness stages and facilitates collaboration between new and experienced clinicians. The sessions, which incorporate researched and innovative therapeutic models, establish a strong foundation for subsequent treatment. Although our study was conducted in a specific community setting, the potential for extending this intervention to diverse contexts underscores its adaptability and capacity to serve underserved communities. The versatile delivery, both in-person and through virtual means, improves accessibility, emphasizing the broad applicability of this psychoeducation intervention.

Acknowledgments

The authors would like to thank Ms. Kylah Blair, Ms. Colleen Steel, Dr. Peter Dodek, Dr. Josie Geller, Ms. Avarna Fernandes, and Ms. Anne Merrett-hiley, for their intellectual input, and the Vancouver Coastal Health Eating Disorders Program staff, for support of this project.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/00207284.2024.2341293.

Additional information

Funding

This work was supported by the Vancouver Coastal Health Research Institute Research Challenge grant, funded by the Robert H. N. Ho Enhancing Patient Care Fund via the VGH & UBC Hospital Foundation.

Notes on contributors

Hella Lee

Hella Lee is a family therapist and social worker who works with children, youth, adults, and families in a publicly funded community eating disorders program. Sameer Desai is an epidemiologist who contributed to this study by conducting the statistical analysis, interpreting the results, and providing critical revisions to this manuscript. You Na Choi is a research assistant and current graduate student with research interests in health inequalities and facilitators and in barriers to treatment access.

Appendix

FUNDAMENTALS GROUP EVALUATION

Please help us improve our program by answering the questions below. We are interested in your honest opinions, whether they are positive or negative. We also welcome your comments and suggestions. Thank you very much.

Circle your answer.

1. Overall, how satisfied were you with the Fundamentals group?

Table

1	2	3	4	5
Dissatisfied				Extremely Satisfied

2. How many sessions of Fundamentals did you attend? ______/10

3. How satisfied were you with the amount of discussion/interaction?

Table

1	2	3	4	5
Dissatisfied				Extremely Satisfied

4. Did the group help you to understand your eating disorder (symptoms, development, function, etc.)?

☐ YES      ☐ NO

5. Which component(s) of the Fundamentals group did you find most useful? Please check.

• Mind/body connection (neuroscience of psychological well-being)

• Self-compassion

• Coping skills (“tool box”)

• Recovery model (hope, self-responsibility, self-advocacy …)

• Understanding underlying issues (iceberg)

• Stages of change

• Function of the eating disorder and decisional balance

• How the media influences our attitudes toward weight and shape

• Thought/feeling/behavior triangle (T/F/B)

• Triggers and thought distortions

• Feelings

• Urges and behaviors

• Other:________________________________

6. Do you feel that the Fundamentals group improved your readiness and motivation to recover?

☐ YES      ☐ NO

In what way(s)?

_________________________________________________________

_________________________________________________________

7. Do you feel that the Fundamentals group improved your quality of life?

☐ YES      ☐ NO

In what way(s)?

_________________________________________________________

_________________________________________________________