神戸学院大学心理学研究 2023 年 神戸学院大学心理学研究
第 6 巻 第 1 号 pp.39-482023 年

第6巻

原著論文

第1号

Original Article（査読あり）

Qualitative analysis of communication to improveself-esteem in group therapy for patientswith bulimia nervosa
Tsuyoshi Takeda (Department of Psychology, Kobe Gakuin University)
In the treatment of bulimia nervosa, attention is focused on the importance of improving self-esteem throughprograms such as “Get Along with Yourself.” Related research and intervention techniques have shown certain
effects with regard to improving patient self-esteem. However, it remains unclear how concrete linguistic
interactions occurred between the facilitator and participants. To clarify this issue through qualitative analysis,
we examined two groups of conversation data. These data totaled approximately 360,000 Japanese characters.
Employing the grounded theory approach, we clariﬁed 15 categories of comments and remarks by the facilitator
and participants. The comments from the facilitator were divided into 9 categories, such as “show interest in
participants,” and the remarks from the participants were divided into 6 categories, such as “disclose participantʼsown experience.” In addition, five interactions occurring between these statements were considered. An
especially eﬀective method for improving the participants' self-esteem is the facilitatorʼs connection with theparticipants in an equal relationship and speech that enhances the sense of unity among the participants, which
can increase their interest in other participants and encourage them to ask questions of one another.
Key words: bulimia nervosa, eating disorders, self-esteem, group therapy, grounded theory approach
Kobe Gakuin University Journal of Psychology
2023, Vol.6, No.1, pp.39-48

It has been repeatedly noted that patients with eating
disorders exhibit low self-esteem. Self-esteem mentioned
here is a sense of evaluation of one's overall condition, in
which one considers oneself "good enough" (Rosenberg,1965). In particular, the relationship between one typeof eating disorder, bulimia nervosa, and low self-esteem
has received considerable attention in recent years, andextensive knowledge, including the theory of symptom
formation and the theory of intervention, has been amassed(Takeda, 2017a).
Takeda and Sasaki (2017) developed a group therapy
called “Get Along with Yourself,” which improves
the self-esteem of patients with bulimia nervosa. This
group therapy consists of 6 sessions, which are 2 hours
each and are conducted every other week. In the grouptherapy, the following points are included as especially
important treatment components. First, the purpose ofthis program is to correct self-concepts to a form in which
self-evaluation can be easily improved, namely, thecorrection of the subjective intensity of oneʼs self-concept
as a method to improve self-esteem. This is based on thetheory that the content of the self-concept, defined as athoughts or feelings that an individual holds about oneself,
influences the level of self-esteem (Rosenberg, 1979).
Six self-concepts such as "I am a perfectionist" or "I havereceived a bad evaluation from others" are targeted forintervention. These are self-concepts that have been shown
to be characteristic of bulimia nervosa by qualitative andquantitative studies in patients with bulimia nervosa (seeTakeda & Sasaki, 2012; Takeda & Sasaki, 2016b; Takeda,
2017b). Interventions that combine cognitive behavioral
therapy are offered to change these self-concepts (seeTable 1).
Second, the "Get Along with Yourself" method conveys
the message, “Think about how to get along with your selfconcept” and subsequently includes a method to improveself-esteem through acceptance of the subjective intensityof self-concepts. This method may seem inconsistent with39

神戸学院大学心理学研究 2023 年

第6巻

第1号

Table 1
Outline of Self-esteem Improvement Programs for Patients with Bulimia Nervosa (“Get Along with Yourself”)

No. Theme

Goals for each session

Task

1

Self-esteem andnegative feeling

Psychoeducation andsetting objectives

2

Perfectionism andnarcissism

3

Fear of negativeevaluation fromothers4

Vacillation ofidentity5

Conflict ininterpersonal
relationships

6

Review and futureplanning

Understand the reason why self-esteem is
kept low and the relationship between
depression and low self-esteem
Understand the relationship between
perfectionism and low self-esteem fromthe perspective of the law of diminishingreturns and self-loving cognition
Understand the relationship between fearof negative evaluation from others andlow self-esteem, and notice themaladaptive cognitions behind that fear
Understand the relationship between
vacillation of identity and low selfesteem, notice what values are mostvalued, and learn the importance of not
losing sight of them
Understand the relationship between
conflict in interpersonal relationships andlow self-esteem, and consider acommunication method with little
discrepancy with the other's expectations
Review the themes dealt with so far, andmake a prediction of points that are likely
to fail after the group ends

the objectives listed above. However, it has been shownthat patients with bulimia nervosa have both a desire to"improve themselves" and a desire to "accept themselves
as they are" (Takeda, 2020). By fulﬁlling both wishes ofthe participants, the program helps participants develop
a new self without losing their present identity, helping
them to finally evaluate themselves as "good enough.”Speciﬁcally, supportive feedback from other patients canbe easily obtained in each session. The “Get Along with
Yourself” group is designed to create more opportunities
for participants to easily share their own experiences toempathize with and support each other.
“Get Along with Yourself” is a beneficial grouptherapy for bulimia nervosa because of its quantitativeand qualitative effectiveness. Takeda and Sasaki (2017)
conducted a quasi-experimental study using an A-B-A
design. This intervention study showed that participants'
subjective strength of self-concept fluctuates and thatparticipants change their self-concepts toward evaluationsof themselves as "good enough.” It has also beenshown that the symptoms of bulimia nervosa diminish
accordingly. In addition, these trends were maintained after
one month. Takeda & Sasaki (2016a) conducted a study tointerview participants about their group experience. The
study found that participants initially resisted joining thegroup. However, the participants then shared the diﬃculty

Psychoeducation andanalysis of positive
and negative aspectsof perfectionism
Reconstruction of
cognition

Task to consider
priority of your own
valuesAssertion training

Write an empathic
letter to yourself

of skill training and praised each other for achieving thetask. Through this process, participants became more readyto take on the task and change themselves.
Nevertheless, the reasons for the increased self-esteemof patients in the group have not been fully identified.
Case formulas such as Takeda & Sasaki (2012) and related
cognitive behavioral therapy improved participants' selfesteem and eating disorder symptoms. Nevertheless, theconnection between improving the self-esteem process andthe communication process in the group is unclear. Why
did the participants get through to the end even though
they faced difficult skills training? How do the goals of“improving yourself” and “accepting yourself” ﬁt together?
Other eﬀective interactions, such as the facilitatorʼs attitude
toward advice or the grouping method, might support
participantsʼ acceptance of their limitations.
Qualitative research is a useful method to reveal how
interaction affects participantsʼ psychological process.
Laberg (2001) examined the experience of patients witheating disorders in cognitive behavior group therapy. Dataobtained through semi-structured interviews were analyzed
using grounded theory analysis, and seven categories
were identified, such as the experience of group therapy.
Skilled therapists may already be unconsciously practicing
these techniques, but for many who do not, knowing how
to interact with and communicate with patients can be a40

Takeda：Qualitative analysis of communication to improve self-esteem in group therapy for patients with bulimia nervosa

guide for treatment. A qualitative analysis of participant
communication in the “Get Along with Yourself” approach
may reveal the key to improving self-esteem in grouptherapy for patients with eating disorders.
The purpose of the present study was therefore to
explore the interaction between the facilitator and theparticipants in “Get Along with Yourself.” Specifically,
we analyzed conversations in group therapy using agrounded theory approach considering the context of theconversation. Three research questions were considered: (1)How does the facilitator talk to the participants to guidethe group? (2) How and about what do participants talkto facilitators and participants? (3) How do the dialogues
between the facilitator and the participants interact tocreate a conversation? Based on these questions, we will
clarify effective communication that can improve theself-esteem of patients with bulimia nervosa and lead to
improvements in group therapy.

were deemed to be patients with eating disorders but withhigh states of self-esteem. The second criterion was having
life-threatening symptoms or having serious psychologicalsymptoms that put the patient into a condition in whichinterventions must be prioritized. The third exclusion
criterion was currently being pregnant. The fourth andlast criterion was an individual at risk of injuring herself
or others or having symptoms that pose a problem toparticipation in group therapy. The last three criteria were
judged by a doctor, who was the director of a departmentof psychosomatic medicine.
The conversation data were collected in twelve sessions
in two groups. Each group was composed of three or four
members and one facilitator. Five members completed
all sessions. All were female, 31.2 ± 5.89 years old, andhad only a diagnosis of bulimia nervosa (see Table 2). In
each group, a male clinical psychologist in his 30s served
as a facilitator. The facilitator had worked in this hospitalfor approximately 10 years. He was familiar with how toproceed with group therapy because he was involved in
the development of group therapy (and he is the authorof this paper). He facilitated the discussion according to
the programme prepared. He was not acquainted withany participant. The conversation data obtained totaled
approximately 360,000 Japanese characters.

Methods
Data Collection
The group therapy took place in the department of
psychosomatic medicine of a hospital in an urban areaof Japan. Patients who met the criteria participated. The
first criterion was that the patient was a female walk-in
patient aged 18 to 50. The second criterion was a diagnosisof bulimia nervosa. The diagnostics used for bulimia
nervosa were DSM-5 criteria based on replies to the Eating
Disorder Examination Questionnaire (EDE-Q (Fairburn,2008)). The exclusion criteria were the following 4 items.
The first criterion was patients with high self-esteem.
Rosenberg's self-respect measure (Rosenberg, 1965) wasused to measure self-esteem. Using this scale, an SD scoreof + 1 or more from the average score reported by Otagaki
et al. (2005) was used as an exclusion criterion (i.e., thereference score was 26.2). Any patients with a higher score

Study Design and Analysis Procedure
Because the notion of the communication process
in a group is a relatively new and under-researchedphenomenon, in this study, we adopted a grounded theory
approach, which has a stricter procedure than traditional
discourse analysis (Corbin & Strauss, 2015). In particular,(1) we divided conversations between the facilitator andthe participants into segments for each block of meaning.
(2) We interpreted those meanings and combined segmentswith similar meanings to generate code. They were codedthat were expected to lead to a change in self-concept that

Table 2
Medical Information of the ParticipantsParticipant
code
P1
P2
P3

GenderAgeSocial Attribution

F
F
F

Late 20s
Late 20s
Early 30s

N/A
Part-time worker
House wife

Diagnosis

Bulimia Nervosa
Bulimia Nervosa
Bulimia Nervosa,
Bipolar Disorder
P4
F
Late 20s
Part-time worker
Bulimia Nervosa
P5
F
Early 40s
Full-time employee
Bulimia Nervosa
Note. Two participants dropped out during the program. Both were women in their 20s,
unemployed, and had a diagnosis of bulimia nervosa. Both attended only the firstsession and did not participate thereafter.

41

神戸学院大学心理学研究 2023 年

would increase self-esteem. This focalization was basedon Takeda (2012) and Takeda & Sasaki (2016a). To avoid
losing the context of the conversation, we included thenarratives of the dropouts in our analysis, but the dropout
narratives themselves were excluded from the coding. (3)We examined whether there was any other interpretation in
the code that was previously generated. We also examined
whether similar cases were conﬁrmed and whether opposite
cases could be found. In parallel with generating code, we
examined the relevance between the new code and othercodes individually. Through careful examination of thesecodes, we prevented the duplication of the meaning of eachcode and prevented the inclusion of codes that were notrelated to the research question. (4) We combined codeswith similar meanings and created categories. In addition,
we combined categories with similar meanings andcreated a category group. Subsequently, the reorganization
was repeated based on the contents and relevance of thecategories. (5) We generated several hypotheses suggestinga causal relationship between categories and generated amodel of communication to improve self-esteem in grouptherapy. Every time we performed these procedures,
we wrote a memo to prevent the researchers' arbitrary
judgment.
The conversations were analyzed in session orderbecause conversation and interaction deepened as
the session progressed. If no new categories weregenerated after the session analysis and the refinement
and reorganization of the categories were judged to be
somewhat stable, we determined that the categories related
to the research question had been suﬃciently created.

第6巻

第1号

participants' motivation. Remarks from participants
were classified into nine categories, which were roughlyclassified in four category groups: remarks to promote
conversation, remarks to enhance participants' senseof unity, remarks expressing concern about the content
of the group, and remarks expressing the benefit of thecontent of the group. Several similar categories wereextracted in relation to comments from the facilitator
to the participants and remarks among the participants.
This approach suggested that the group may be formedby repeating a similar relationship between the facilitator
and the participants. Considering this point, we gained thenew perspective that there was no hierarchical relationshipbetween the facilitator and the participants, and they werebuilding a cooperative relationship and managing thegroup from the early stage.
Throughout the analysis of the second session and thethird session, 58 codes were labeled for 1,409 segments
and were classified into 17 categories. The codes
continued to increase in these sessions. In particular, thenumber of codes on the performance of the task increased.
By addressing the tasks, the interaction between theparticipants and facilitators and among the participants
increased. Rather than simply interrogating interactions,interactions with an intention to build emotional ties
with members increased, such as praise, self-disclosure,and relationship building. From the perspective thatthe facilitator and the participants are in a cooperative
relationship, the "disclosure of own experiences from thefacilitator to participants" code was generated, and thiscode was added to the category “link participants andfacilitator in an equal relationship.”Throughout the analysis of the fourth session and theﬁfth session, 56 codes were labeled for 2,488 segments andwere classiﬁed into 15 categories. No new category or code
was generated in the analysis of either session. Although
there was code movement between several categories, thename of the category did not change. From these ﬁndings,
we expected that the categories related to researchquestions were generated without excess. Taking thisresult into account, we analyzed the sixth session. Some
codes were labeled in the 234 segments, but no new codes
or categories were added. We then asked one external
researcher to check the validity of the categorization.
Although the names of some codes were changed, it wasdetermined that there was no need to change the content
or name of the categories. Finally, the comments fromthe facilitator were divided into three category groups,
which consisted of 9 categories. The remarks from theparticipants were divided into three category groups, which
consisted of 6 categories (see Tables 3-1, 3-2).
We considered hypotheses suggesting a causal

Ethics Approval and Consent to Participate
Prior to this study, the Naniwa Ikuno Hospital
Institutional Review Board approved the implementationof “Get Along with Yourself” on June 24, 2014, andAugust 23, 2017. Each participant gave informed
written consent upon attendance in the group therapy.
Additionally, The Kobe Gakuin University Faculty ofPsychology Institutional Review Board approved thisstudy for secondary use of data obtained in the above study(Certiﬁcate HP18-04).

Results
Through analysis of the first session, 46 codes werelabeled for 458 segments and were classified into 18
categories. This result included ten categories related tocomments from the facilitator. These comments wereroughly classified into three category groups: comments
to promote participants' remarks, comments to enhance
participants' sense of unity, and comments to enhance42Takeda：Qualitative analysis of communication to improve self-esteem in group therapy for patients with bulimia nervosa

relationship between categories related to the facilitatorʼscomments and the participantsʼ remarks. Finally, ﬁve casesof a causal relationship were considered (see Table 4-1,
4-2). Combining these cases enabled a model showing theinteraction occurring within the group to be created (seeFigure 1).

Discussion
The purpose of the present study was to explore theinteraction between the facilitator and the participantsin “Get Along with Yourself.” As a result of analyzing
the dialogue of the two group therapy sessions using a

Table 3-1
Category List of Interactions from Facilitator

CG1: Comments to promote participants' remarks
C1-1: Show interest in participants (179)
A method of involvement of the facilitator such as assessing the participants'
attitudes and conditions and remembering participants' remarks about the theme.
C1-2: Promote efforts for group tasks (491)
A method of involvement of the facilitator such as asking participants about theirown experiences and thoughts related to the task, asking questions of theparticipants, and encouraging participants to tackle the tasks.
C1-3: Make use of participants' remarks (205)
A method of involvement of the facilitator such as asking another participant
based on participants' remarks, connecting to new topics based on their remarks,
and providing psychoeducation based on their remarks.
C1-4: Accept participants' remarks (349)
A method of involvement of the facilitator such as expressing that the facilitator
understands what the participants are attempting to express and reflecting theparticipants' remarks.
CG2: Comments to enhance participants' sense of unity
C2-1: Enhance participants' sense of unity(78)A method of involvement of the facilitator such as combining participants with asimilar opinion, implying that other participants have the same opinion, andproviding psycho-education based on common terms of eating disorders.
C2-2: Link participants and facilitator in an equal relationship (127)A method of involvement of the facilitator such as telling participants that bothparticipants and facilitators are equal, telling the participants that the facilitator
has the same opinion as the participants, and disclosing the facilitator's own
experience.
C2-3: Accept participants' diverse experiences (108)
A method of involvement of the facilitator such as accepting participants' diverse
experiences, accepting participants as they are, and providing psychoeducationby considering diversity.
C2-4: Forgive participants' failure (169)
A method of involvement of the facilitator such as allowing participants to workon tasks freely, accepting imperfect results of tasks, and normalizing
participants' feelings of insufficiency.
CG3: Comments to enhance participants' motivation
C3: Enhance participants' motivation (82)
A method of involvement of the facilitator such as praising participants' efforts
and telling the participants that the content of the group will meet their
expectations.
Note. The names of participants (such as Hanako) in the table are fictitious. CG means category group,and C means category. The number in parentheses in the category name column indicates the numberof segments.

43

神戸学院大学心理学研究 2023 年

第6巻

第1号

Table 3-2
Category List of Interaction from Participants

CG1: Remarks to promote conversation
C1-1: Show interest in other participants (99)
A method of involvement of the participants such as connecting to new topics
based on their remarks and reflecting other participants' remarks.
C1-2: Ask other participants (64)A method of involvement of the participants such as asking other participants andsuggesting ideas to other participants.
CG2: Remarks to enhance participants' sense of unity
C2-1: Enhance participants' sense of unity (77)
A method of involvement of the participants such as telling other participants thatthey have the same opinion and trying to save other participants' face.
C2-2: Disclose participant's own experience (248)
A method of involvement of the participants such as disclosing everyday
experiences to other participants and disclosing feelings generated in the group toother participants.
CG3: Remarks to evaluate the content of the group
C3-1: Concern about the content of the group (192)
A method of involvement of the participants such as expressing unacceptabilityof the content described in the group and suffering from conflict with previous
countermeasures.
C3-2: Expressing the benefit of the content of the group (214)
A method of involvement of the participants such as telling the facilitator that a
new awareness has been obtained and telling the facilitator that the explanation
was convincing.
Note. The names of participants (such as Hanako) in the table are fictitious. CG means category group, andC means category. The number in parentheses in the category name column indicates the numberof segments.

44

Takeda：Qualitative analysis of communication to improve self-esteem in group therapy for patients with bulimia nervosa
Table 4
An Important Causal Relationship between Obtained Categories

H1: Participants disclose their own experience as the facilitator shows interest in
participants or promotes efforts for group tasks. Subsequently, the facilitator
accepts the participants' remarks and their diverse experiences.
(e.g., Facilitator: 'May I explain a bit more about what Hanako said, "I am not worthyof a good evaluation at this time"?' ("promote efforts for group tasks"
category)
Hanako: 'Last year I was fat. Now I am trying hard to be thin, but the people
around me are worried that it is better to eat more just by looking at me.
First of all, I would like you to praise my own efforts that I've made sofar.' ("disclose participant's own experience")
Facilitator: 'Ah, that makes sense.' ("accept participants' remarks") 'Even though
you have worked hard, it is sad that you will not be evaluated at thatpoint.' ("accept participants' diverse experiences"))
H2: Participants' concern about the content of the group as the facilitator promotes
efforts for group tasks. Subsequently, the facilitator forgives participants' failure.
(e.g., Facilitator: 'The content you contemplated today is important, so I do not want
you to forget it.' ("promote efforts for group tasks")
Saki: 'Today's task was difficult for me, and I could not achieve it enough.'("concern about the content of the group")
Facilitator: 'That is because it is not important to get results.' ("forgive
participants' failure"))H3: Participants show interest in other participants or ask other participants as thefacilitator links participants and himself in an equal relationship.
(e.g., Haruka: 'Although I do not want time spent alone, the test showed that I thought
unconsciously that time is important.'
Facilitator: 'From the results of the test, I also said that loneliness will heal me,
like you.' ("link participants and facilitator in an equal relationship")
Hanako: 'I also got results like that. I think it is absolutely necessary to have time
to be alone.' ("show interest in other participants"))
H4: Participants show interest in other participants or ask other participants as thefacilitator enhances the participants' sense of unity.
(e.g., Aoi: 'I informed my boss at work and asked for understanding that I had an eating
disorder. Nevertheless, my colleague sees me as a person with a weak will.'
Facilitator: 'Regarding the lack of understanding of symptoms, I often talk with
doctors in psychosomatic medicine. I think what you said now isexactly the same as what many patients feel.' ("enhance participant's
sense of unity")
Saki: 'I cannot confess "I am suffering from eating disorders.” Perhaps people will
see me as a freak.' ("show interest in participants"))
Note. The names of participants (such as Hanako) in the table are fictitious.

45

神戸学院大学心理学研究 2023 年

第6巻

第1号

Table 4 (Continued)
An Important Causal Relationship between Obtained Categories

H5: Participants disclose their own experience as other participants show interest inthem. Subsequently, participants enhance their sense of unity.
(e.g., Hanako: 'The next day when I overate and vomited, I felt sick, like my body would
not move at all.'
Haruka: 'I imagine that is a terrible hangover.' ("show interest in otherparticipants")
Hanako: 'Exactly. For that, I often rest in the infirmary at my office. I am scaredbecause my boss urges me to quit my job.' ("disclose participant's own
experience")
Haruka: 'That is a very painful situation.' ("enhance participant's sense of unity"))Note. The names of participants (such as Hanako) in the table are fictitious.
Figure 1
Model of the Interaction Occurring within “Get Along with yourself”

Facilitator
Comments to promote participants’ remarks
Make use ofparticipants’ remarks

Accept participants’ remarks

Show interest in participantsComments to enhance participants’sense of unity
Promote efforts
for group tasks

Participants2

Forgiveparticipants’failure1

Link participants
and facilitatorin an equal
relationships

4

3

2

Enhanceparticipants’sense of unity

Acceptparticipants’
diverseexperiences

Group progress

1Concern about
the content of the group

Disclose
participants’
own experiences

Enhance
Participants’motivation

Expressing benefit of thecontent of the group

5Show interest in other participants
Ask other participants

5

Enhanceparticipants’sense of unity

Note. The numbers in the arrows correspond to the numbers of important causal relationships (see Table 4).

grounded theory approach, 15 categories were obtained
and five cases of causal relationships were considered.
Among the obtained categories, basic techniques for
operating group therapy were also included (e.g.,
categories to promote participantsʼ remarks, such as “showinterest in participants” and “make use of participantsʼ
remarks”). In the created model diagram, the participants
show interest in other participants or ask questions ofother participants as the facilitator links the participants

and himself in an equal relationship or as the facilitator
enhances the participants' sense of unity. As shown in
Hypotheses 1 and 5 (see Table 4), these efforts by thefacilitator to increase participants' remarks and increase thesense of unity among them have been practiced in manygroup therapy strategies (e.g., Fehr, 2003).
The remaining three hypotheses about communication
represent important new ﬁndings. The ﬁrst important pointis that the hierarchical relationship between the facilitator

46

Takeda：Qualitative analysis of communication to improve self-esteem in group therapy for patients with bulimia nervosaand the participants was no longer seen from the earlystage of the group therapy, and their relationship involved
operating the group in collaboration (this point is related
to Hypothesis 3 in Table 4). Because the techniques ofcognitive behavioral therapy that were also adopted in thisgroup include many elements of coaching, facilitators incognitive behavioral group therapy tend to take leadershipof the participants (Bieling et al., 2009). In comparison,
the facilitator in this group did not participate in the groupas a coach but, rather, to self-disclose and equalize thegroup. The structure in which the facilitator speaks in thesame position as the participants is similar to encountergroups. Rogers (1973) suggested that it is important
for the facilitator to be a promoter but also to become aparticipant, and it is important for the facilitator to express
his emotions and thoughts, which will encourage theparticipants' self-growth. This point likely contributes toalleviating patientsʼ sense of resistance to group therapy.
It has been suggested that patients with eating disorders
exhibit a higher dropout rate in group therapy than in
individual therapy (Garner et al., 1987). This effect isthought to be related to fear of negative evaluation, which
is characteristic of patients with bulimia nervosa, as
indicated by Takeda & Sasaki (2016b), and the equality
among the group that the facilitator produces is thought toease the patientsʼ fear.
Likewise, it is eﬀective for the facilitator to understandwhat aspects of the group therapy task the participants ﬁnd
diﬃcult and what theories of group therapy the participants
find difficult to accept. When difficulties and failures
are expressed by the participants, it is also beneﬁcial forthe facilitator to embrace them (this point is related toHypothesis 2 in Table 4). According to Takeda & Sasaki(2016a), who conducted process research on the eﬀect of
the group, it is important that participants change the belief
that they should not fail, and it is argued that abandoning
this belief will create room to incorporate various ideas.
The involvement of facilitators who allow participants
to fail has a positive effect on this first point. A positive
cycle is also created that makes it easier for participants
to express concern about the content of the group by
witnessing other participants doing so and witnessing thefacilitator accepting this.
In addition, it may be effective to explain that many
patients are working on improving their self-esteem andtreating eating disorders (this point is related to Hypothesis
4 in Table 4). Takeda & Sasaki (2016a) suggested that it
is important for participants not to abandon their future
in an unhealthy way but to make a "positive resignation"
to live with themselves even though they are not goodenough. Regarding this point, it seems that the facilitator's
acceptance of diversity and increasing the sense of unity ofthe participants, as shown in this research, has a positiveinﬂuence. Participants may achieve "positive resignation"
by noticing that they are accepted by others regardlessof whether they fail and by recognizing that there arecompanions who will build new selves together.
There are some limitations to this research. First, it isnecessary to analyze more sessions. More data are needed
to form a theory that is applicable to more groups and moreparticipants. Second, only groups in which the facilitator
was male were analyzed in this study. If the facilitator is awoman, diﬀerent interactions may occur. Similarly, cases
where participants include men (or only men) need to beconsidered. These may result in changes in communication
patterns (e.g. less direct emotional expression whenparticipants are male only). Third, a distinction needs tobe made between the eﬀects of the communication modelin "Get Along with Yourself" shown in this study and theeﬀects of the cognitive-behavioral therapy skills provided
therein. This study also provides various possibilities for
future research. First, an eﬀect study could be conductedon the extent to which the ﬁndings obtained in this researchcontribute to the improvement of self-esteem and theimprovement of symptoms. This objective can be achievedby comparing the group therapy conducted with emphasison the relationship obtained in this study and ordinarygroup therapy. Second, it would be beneﬁcial to investigate
the extent to which participants in group therapy actually
feel that group facilitators are attempting to build groupequality through self-disclosure. This can be confirmedin the follow-up interviews after the completion of grouptherapy. Finally, it would be beneﬁcial to investigate how
the therapy and patient conversations in individual therapychange when the findings of this study are practiced inindividual therapy. By using qualitative analysis similar tothis research and quantitatively measuring the change inself-esteem, we will be able to study the versatility of theﬁndings of this study.

Funding
This study was supported by JSPS KAKENHI Grant
Number JP18H05822. This financial support was mainly
used to analyze the text data. The implementation of “GetAlong with Yourself” was supported by JSPS KAKENHI
Grant Number JP 25965. This ﬁnancial support was mainly
used to develop the group therapy.

Conflict of Interest
The authors declare no conflicts of interest associatedwith this manuscript.

47

神戸学院大学心理学研究 2023 年

第6巻

第1号

Takeda, T. (2012). Eating, the self, and interpersonal
relations: Using a modiﬁed grounded theory approachto analyze the self-narratives of patients with bulimia
nervosa. Japanese Journal of Educational Psychology,
60, 249-260. https://doi.org/10.5926/jjep.60.249 (InJapanese with English abstract.)
Takeda, T. (2017a). Bulimia nervosa and self-esteem.
Japanese Journal of Psychosomatic Medicine, 57,
896-901. https://doi.org/10.15064/jjpm.57.9_896 (InJapanese with English abstract.)
Takeda, T. (2017b). Development of Bulimic Personality
Assessment Sheet. Japanese Journal of Counseling
Science, 49, 64-74. (In Japanese.)
Takeda, T. (2020). The process of change provided by “GetAlong with Yourself”. Bulletin of Clinical Psychology
counseling Center, Kobe Gakuin University, 13, 27-36.
(In Japanese.)
Takeda, T., & Sasaki, J. (2016a). Qualitative assessmentof group therapy for improvement of self-esteem forpatients with bulimia nervosa. Annuals of Educational
Studies Osaka University, 21, 29-41.
Takeda, T., & Sasaki, J. (2016b). Developing the model ofthe self-concepts of the patients with bulimia nervosa.
Bulletin of Psychological Clinic, Osaka University, 21,
35-42. (In Japanese.)
Takeda, T., & Sasaki, J. (2017). Quantitative assessment ofgroup therapy for the improvement of self-esteem forpatients with bulimia nervosa. Osaka Human Sciences,3, 1-17. https://doi.org/10.18910/57423

References
Bieling, P. J., McCabe, R. E., & Antony, M. M. (2009).
Cognitive-behavioral therapy in groups. Guilford
Press.
Corbin, J. M., & Strauss, A. L. (2015). Basics of qualitative
research : Techniques and procedures for developing
grounded theory (4th ed.). SAGE.
Fairburn, C. G. (2008). Cognitive behavior therapy andeating disorders. Guilford Press.
Fehr, S. S. (2003). Introduction to group therapy: A
practical guide (2nd ed.). Haworth Press.
Garner, D. M., Fairburn, C. G., & Davis, R. (1987).
Cognitive-behavioral treatment of bulimia nervosa: A
critical appraisal. Behavior Modification, 11, 398-431.
https://doi.org/10.1177/01454455870114002
Laberg, S. (2001). Experiences of patients in cognitive
behavioural group therapy: A qualitative studyof eating disorders. Scandinavian Journal of
Behaviour Therapy, 30, 161-178. https://doi.
org/10.1080/02845710127474
Otagaki, Y., Yonezawa, H., Shiwa, S., Saito, H., &Nakamura, K. (2005). Self-esteem in eating disorders.
Japanese Journal of Psychosomatic Medicine, 45,
225-231. https://doi.org/10.15064/jjpm.45.3_225 (InJapanese with English abstract.)
Rogers, C. R. (1973). Carl Rogers on encounter groups.
Harper & Row.
Rosenberg, M. (1965). Society and the adolescent selfimage. Princeton University Press.
Rosenberg, M. (1979). Conceiving the self. Basic Books.

―2023.8.30 受稿

48

2023.11.15 受理―