Transcript Eating Disorders, Sexual Trauma and Group Therapy

Eating Disorders, Sexual
Trauma and Group Therapy
Lana Bentley
MSW RSW.
03.28.09
Agenda
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Definitions: eating
disorders
Trauma
The research: is there a
connection?
Group therapy: how does
it look in practice?
Acronyms
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AN: Anorexia Nervosa
BN: Bulimia Nervosa
EDNOS: Eating Disorder Not
Otherwise Specified
CSA: Childhood Sexual
Abuse
SA: Sexual Abuse
CEDP: Calgary Eating
Disorder Program
Eating Disorders Defined
DSM lV-TR
Anorexia Nervosa
A. Refusal to maintain body weight at or above the
minimally normal weight for age and height.
B. Intense fear of gaining weight or becoming fat, even
though underweight.
C. Disturbance in the way in which one’s body weight or
shape is experienced, undue influences of body weight or
shape on self-evaluation, or denial of the seriousness of
the current low body weight.
D. In Post menarchal females, amenorrhea (absence of at
least 3 consecutive menstrual cycles).
Sub-type:
restricting type: Person has not regularly engaged in
binge-eating or purging behavior (i.e. self-induced
vomiting, misuse of laxatives, diuretics, or enemas).
Binge-Eating/Purging type: Person regularly engages in
in binge-eating or purging.
Bulimia Nervosa
A. Recurrent episodes of binge eating. Binge eating is
characterized by both:
1)
Eating in a discrete period of time (e.g. within
a 2 hr period), an amount of food that is
definitely larger than most people would eat
during a similar period of time and under
similar circumstances
2)
A sense of lack of control over eating during
the episode (e.g. feeling out of control).
B. Recurrent inappropriate compensatory behavior in
order to prevent weight gain, such as selfinduced vomiting, misuse of laxatives, diuretics,
enemas, other medications, fasting or exercise.
C. The binge eating and inappropriate compensatory
behaviors both occur, on average, at least twice
a week for 3 months.
Eating Disorder Not Otherwise
Specified
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For females, all of the criteria for AN is met except
that the individual has regular menses.
All of the criteria for AN are met except that,
despite significant weight loss, the individual's
current weight is in the normal range.
All of the criteria for BN are met except that the
binge eating and inappropriate compensatory
mechanisms occur at a frequency of less than
twice a week for a duration of less than 3 months.
The regular use of inappropriate compensatory
behavior of an individual of normal body weight
after eating small amounts of food
Repeatedly chewing and spitting out, but not
swallowing, large amounts of food.
Children and Eating
Disorders
Is it an Eating Disorder?
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(Laske and Waugh, 2007)
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Food avoidance
emotional disorder
Selective eating
Restrictive eating
Food refusal
Specific fear or phobia
leading to avoidance of
eating
Pervasive refusal
syndrome
Appetite loss
secondary to
depression
Early Onset
Early Onset: refers to children ages 7 to 14 with an
eating disorder or disturbance
 The youngest you can diagnose an eating disorder: 8
(Laske and Waugh, 2007)
 The CEDP defines early onset as 13 and under
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Trauma
Trauma Defined
“In 1980, when post-traumatic stress disorder was first
included in the diagnostic manual, the American
Psychiatric Association described traumatic events as
‘outside the range of human experience’. Sadly this
definition has proved to be inaccurate. Rape, battery, and
other forms of sexual and domestic violence are so
common a part of women’s lives that they can hardly be
described as outside the range of ordinary
experience...Traumatic events are extraordinary, not
because they occur rarely, but rather because they
overwhelm the ordinary adaptations to life.”
(Herman, 1997)
Psychobiological Symptomology
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Physiological Arousal
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Most people who
experience severe stress
develop intrusive
symptoms
Persistent intrusive
symptoms leads to
disordered pattern of
arousal
Loss of Emotional
Signals
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Arousal and failure to
regulate reactions to
internal and external
stimuli affect people’s
ability to regulate
emotion
(van der Kolk & van der Hart, 2007)
Abnormal Reactions
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Response to reminders of
the trauma
 Heightened arousal to
sounds, images, and
thoughts related to
traumatic incident
Response to neutral
stimuli
 Traumatized people
have difficulty
evaluating different
stimuli
(van der Kolk & van der Hart, 2007)
What is Post Traumatic Stress
Disorder?
Principles of Treatment
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Safety and predictability is vital
Aim of therapy: move from being haunted by the past to
being fully engaged in the present
Person must incorporate the terrifying event in to their
self-concept.
Psychotherapy: 1) de-conditioning of anxiety; 2) altering
the way person sees themselves and the world by reestablishing a feeling of integrity and control
Phases of Treatment
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Stabilization
De-conditioning
Restructuring
Reestablishment of
secure social connections
Accumulation of restitutive
emotional experiences
Guidelines for Treatment
1.
2.
Therapist maintains empathic stance with client,
helps client stay grounded in the here-and-now.
Therapist harnesses strong feelings that are being
directed towards him or her.
Therapist uses words to describe feelings in the
here-and-now that could also be applicable to the
past trauma. Ultimately it is patient who
reconstructs (describes) traumatic event.
(Lindy, 2007)
Client Population & Sexual
Trauma
The Calgary Eating Disorder Program
Background
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Case managers completed a survey on 226 active files at
the Calgary Eating Disorder Program
Case managers also serve as primary therapists (trained
at the graduate level in social work and psychology)
Case managers were asked to review their case loads
and identify cases of sexual abuse (contact or noncontact abuse)
Case managers differentiated between therapistidentified and client-identified abuse
Considerations
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Survey responses will be somewhat biased by the family
therapist and their willingness to suggest whether they
suspect a client has been sexually abused.
Some family therapists are new to the program and thus
may not have had sufficient time to establish a rapport
with their clients which would provide a safe environment
for the client to disclose any form of abuse or details
pertaining to such an event.
Key Terms: Contact Abuse
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Abuse that involves physical
contact between perpetrator
and victim. Abuse involving
sexual contact, fondling,
groping, rubbing genitals
against victim's body,
attempted or completed
vaginal intercourse, oral sex,
anal penetration.
(Wyatt & Peters as cited in
Anderson et el., 1997)
Key Terms: Non-Contact
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Abuse that does not involve physical contact between
perpetrator and victim. Exposure to genitals, solicitation
to engage in sexual activity, forced exposure to
pornography. Also included in this area is "sexual
exploitation", for example, forcing victim to engage in
prostitution, forced participation in making films or
photographs of a sexual nature etc. Ritual abuse can
also be included.
(Wyatt & Peters as cited in Anderson et el., 1997)
Client Population
Primary Diagnosis
80
Frequency
60
40
20
0
EDNOS
Bulimia Nervosa
Anorexia
Nervosa
Not assigned
Primary Diagnosis
Early Onset
(AN-R)
Contact Abuse
200
Frequency
150
100
50
0
None
Patient Identified
Therapist Identified
Contact Abuse
Insufficient Information
Contact Abuse Frequency
25
Frequency
20
15
10
5
0
Single Event
Multiple Events
Several Events
Repeated
Non Contact Abuse
250
Frequency
200
150
100
50
0
None
Patient Identified
Non Contact Abuse
Insufficient Information
Considerations
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The vast majority of patients are female, very few male
patients
All of the family counsellors/case managers are female
Staff do not adhere to a set protocol to screen for sexual
abuse (or any trauma)
We do not screen/diagnose PTSD
What do we mean by “EDNOS”?
BREAK
What is the Link?
Based on the work of Lisa Brown (1997)
Pseudo Control
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Incest may result in a greater loss of control- it’s more
reasonable to expect that a stranger might attack us but
when a family member does it, that is the ultimate
betrayal/surprise (abuse by a stranger makes you a
victim of “chance”)
Anorexia may be a means to control/manipulate a parent
who failed to protect victim/survivor from abuse
Eating rituals provide a sense of control
Punishment, Shame and
Control
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Guilt motivates behaviours to punish one’s self (i.e.
Throwing up)
Vomiting may represent an act of control or resistance
(i.e. Women may throw up after being forced to perform
certain sexual act and thus equate throwing up with
“rejecting the act of abuse”)
Self-destructive actions = identifying with the aggressor
Eating behaviours might make survivor less
appealing/attractive to attackers
Food and Abuse
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Being physically forced to eat spoiled food or vomit
Physical abuse at the table or excessive conflict at meal
times
“Junk” food used as a reward for complying with abuse
Overeating to reduce anxiety of upcoming abuse
Food being used in sexual acts
Avoidance of phallic foods
Weight gain is equated with becoming “Big” and
“Strong”, qualities that are attributed with being
aggressive, like the abuser
(Goodwin and Attias, cited in Brown, 1997)
What Does the Research Say?
The Link Between Sexual Abuse and Eating Disorders
The Results are Mixed...
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SA is present in 4 to 53% of AN clients and 12 to 75% of
BN clients (Deep et. al, 1999)
Rates of childhood sexual abuse in the general
population are comparable to rates of childhood sexual
abuse in eating disorder populations (Casper and
Lyubomirsky, 1997)
The results vary depending on which study you review
Why are there Variations in
the Research?
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No universal definition of childhood sexual abuse
No reliable instrument for assessing sexual abuse
Inconsistencies in defining eating disorders
Community comparison groups are rarely included in
these studies
(Deep, Lilenfield, Plotnicov, Pollice, and Kaye, 1999)
Variations Continued
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Many studies on SA and ED have flawed methodology
Therapists in clinical settings might be looking for sexual
abuse among their eating disorder clients, they may
notice SA and ED cases and overlook ED cases where
SA is not present
(Perkins and Luster, 1999)
Is there a Connection?
Definition: Mediating Factors
Sexual
Abuse
- Drugs
- Shame
- Family Conflict
- Personality
Disorder
Eating
Disorder
Childhood Sexual Abuse and Bulimia:
Mediating Role of Core Beliefs
(Waller et. al)
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61 women who met criteria for BN, BED, or AN-BP as
defined by the DSM-IV
Young’s Schema Questionnaire (higher score means
more negative core beliefs), Beck Depression Inventory,
Dissociative Experiences Scale (Revised)
Women reporting CSA had higher schema questionnaire
scores
Certain core beliefs mediated the link between CSA and
eating disorder behaviours
Childhood Sexual Abuse and Anorexia
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Carter, Bewell, Blackmore and Woodside (2006)
Aim: To examine the impact of CSA on the clinical
features of AN and termination of treatment
77 participants
Beck Depression Inventory II, Rosenberg Self-esteem
scale, Padua Inventory (measures OCD), Brief
Symptom Inventory and Inventory of Interpersonal
Problems
48.1% of participants reported history of CSA
51.4% of those who were abused were abused by a
family member or acquaintance
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Patients with CSA history had greater psychiatric comorbidity than patients without CSA
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Higher levels of depression and anxiety
Greater interpersonal problems
More severe OCD symptoms
Patients with CSA history and AN-BP subtype terminated
treatment at an earlier rate
Intrafamilial Sexual Assault
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Baldo, Wallace and O’Halloran (1996)
395 female undergraduate students
Weight Management Questionnaire and Sexual
Experiences Survey
248 women reported that they had been assaulted
Women who were assaulted by family members
were more likely to report serious eating
disturbances
Sexual Abuse and Purging
(Perkins & Luster)
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7,903 women from a mid-western state, ages 12-17
Attitude and Behaviour Questionnaire, one question
asked about purging behaviour
Only people who purged two or more times a week
were included
Key findings
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As family support and parent-adolescent communication
increased, likelihood of purging decreased
Physical abuse related to purging behaviour
Adolescents who reported having multiple adults (others than
parents) to talk to were more likely to engage in purging
behaviours
Unwanted Sexual Experiences as a
Predictor of Bulimic Eating Patterns
(Casper & Lyubomirsky)
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Aim: to explore the nature of the relationship between
unwanted sexual encounters, bulimic behaviours,
individual psychiatric symptoms, and psychiatric
morbidity in family members
61 women, aged 16 to 54, seeking treatment for an
eating disorder
Control group consisted of 92 women, aged 14 to 63
Eating Attitude Test, BMI, open-ended interview, Beck
Depression Interview
Individual’s psychological functioning mediates the
impact of sexual abuse on bulimic behaviours
Sexual Abuse, Substance Abuse,
and Bulimia Nervosa
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Deep et. al. (1999)
Women divided in to three groups (26 AN, 20 BN + SDD,
27 BN – SDD). Control group had 44 women.
Schedule for Affective Disorders and Schizophrenia Life
time (SADS-L), interviews with family members
65% of BN+SDD reported sexual assault, 37% of BNSDD reported sexual assault as did 23% of AN. Control
group, 7%.
Group Therapy
Key Messages
 “You
are safe here”
 “It was not your fault”
 “Nobody deserves to be abused”
Is This the First Time They Have
Talked about the Abuse?
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What allowed you to open up to the group?
What made it safe for you to share today?
What language should we use to talk about this
experience?
Can you tell the group what you need?
Previous Disclosures
Specific to Children
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“Kids are NOT responsible for the choices that adults
make.”
“Adults are responsible for their behaviour.”
(Assess whether they are still in contact with the person
who abused them)
Connecting the Dots
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What did it feel like to share that with the group?
What feelings are coming up for you right now?
What are you noticing in your body right now?
Where in your body are you noticing your feelings?
(Arms, legs, toes etc.)
Therapist Self-Disclosure
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“Therapist self-disclosure
is not a single entity but a
cluster of
behaviours...Some clarity
may be provided by
delineating three realms of
therapist disclosure: 1) the
mechanism of therapy; 2)
here-and-now feelings;
and 3) the therapist’s
personal life.”
(Yalom, 2002)
Self-Reflection
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What are your thoughts
and feelings about sexual
abuse?
What reactions do you
have when somebody
makes a disclosure in
front of you?
What message do you
communicate to clients
about abuse?
It’s Treatment Time, Do You Know
Where Your Group Is?
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How would you handle this...You suspect that Erin, a 28 year old
with a diagnosis of AN-R is about to disclose a history of
childhood sexual abuse in group today. Prior to group she told
that she was finally ready to break the silence on this subject.
She shares with you that she tried to tell her mother about the
abuse however; her mother didn’t believe her. In group, Erin
starts to talk about how she is recognizing that she needs to open
up more to the group. As you look around, you notice that half of
the group members have yet to speak. There are two new group
members who appear distracted and nervous. Another group
member keeps talking about lunch. Would you address the group
dynamic or focus on Erin's new found interest in opening up to the
group.
Consider where the group is at. What kind of a response is Erin
likely to get from the group as it stands now?
Group Cohesion
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Members of a cohesive group:
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Try harder to influence other group members
Are open to feedback from other group members
Are more willing to listen to others and accept others
Experience relief and tension from the group
Participate more
Self-disclose more
Protect group norms
(Yalom, 2005)
Self-Disclosure in Group
“What is truly validating to the client is to reveal
oneself and then to be accepted and supported.
Once that happens, the client experiences a
genuine sense of connection and of
understanding.”
“Clients often manifest great resistance to selfdisclosure...Group members often entertain some
calamitous fantasy about self-disclosure; to
disclose and have that calamitous fantasy
disconfirmed is highly therapeutic.”
(Yalom, 2005)
Is the Group Ready?
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If TRUST and COHESION are missing, the group is not
safe for disclosure. Therapists have a role to play in
assessing these factors.
A room full of people DOES NOT equal a group
“Often the first step toward revealing something to a
spouse or a potential close friend is the first-time
disclosure in the group.” (Yalom, 2005)
Involving Other Group Members
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Marco, can you tell Sally
what feelings are coming
up for you now that she
has told the group she
was sexually assaulted?
Can you tell the group the
group how you feel about
abuse?
Can you connect with the
shared experience of
feeling disempowered?
Involving Men
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Janine, can you talk to
Denise a bit about your
reaction to her story?
Can you tell her what
feelings you can relate to?
Can you tell the group
how you have
experienced feelings of
guilt or shame in your life?
Involving Those Who Have Not
Experienced Abuse First Hand
How Do We Engage Clients Who Have
not Been Assaulted?
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Therapists should be extracting themes for the
group
The themes should anchor the discussion for all
group members i.e., anger, shame, empowerment,
over-coming challenges
Incorporating the idea, “The Personal is the
Political”, challenge clients to recognize other ways
that they perpetuate violence against others or
ways that violence has been perpetuated against
them (unrealistic ideals from the fashion industry,
gender stereotypes, lack of women in leadership
positions etc.)
It’s Not about the Details
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Group psychotherapy has more to do with the Here-andNow than the There-and-Then
It’s a balancing act of creating space for people to share
while not spreading around details
If a client expresses a desire to share their story in detail,
that can be a discussion after group with their therapist
What is helpful for the group?
What kinds of conversations will promote growth and
development?
Here and Now: the Process
Here
and
Now
Stages for Clients
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4.
5.
6.
Clients must recognize what they are doing with other
people
Clients must appreciate their impact on others
Clients must determine if they are satisfied with their
interpersonal skills
Client wants to change
Client transforms their desire into action
Client takes change from group to their life
(Yalom, 2005)
Would These Responses be Helpful?
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It sounds like you’re not
sure if you were really
raped. Maybe that
means you weren’t.
Look, if you decided not
to press charges, the
incident probably wasn’t
that bad.
It sounds like your first
time wasn’t great. I’m
sure you’re next
experience will be
better.
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You haven’t pressed
charges? Aren’t you
worried that this sicko
could assault somebody
else?
Now that you’ve shared
this, you should really
start the healing process
so that you can move on.
Why were you drinking?
Getting drunk was pretty
risky don’t you think?
At First Glance...
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“Has anybody else noticed how provocatively Anne
dresses? She’s only 15! I’m going to tell her to cover
up, her attire is offensive.”
“Shiloh disclosed that she’s been having one night
stands. I think she’s addicted to sex.”
“Kelly never talks in group and she always sits with her
chair pushed close towards the wall. I get the sense
she doesn’t want to be in treatment.”
“Has anybody else noticed that Jessica talks in a weird
baby voice some times? Maybe she’s mentally
challenged.”
“Munro is such a bully in group, he’ always interrupting
people and he can’t handle it when other group
members seem upset.”
Look Again...
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This time, keep in mind that the client has experienced a
sexual trauma.
Would knowing that there was a trauma make a
difference in how you view the client’s behaviours?
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“Has anybody else noticed how provocatively Anne dresses?
She’s only 15! I’m going to tell her to cover up, her attire is
offensive.”
“Shiloh disclosed that she’s been having one night stands. I think
she’s addicted to sex.”
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“Kelly never talks in group and she always sits with her chair
pushed close towards the wall. I get the sense she doesn’t want
to be in treatment.”
“Has anybody else noticed that Jessica talks in a weird baby voice
some times? Maybe she’s mentally challenged.”
“Munro is such a bully in group, he’ always interrupting people and
he can’t handle it when other group members seem upset.”
Are these behaviours responses to trauma?
How Would you Handle This?
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Aubrey is 19 years old with a diagnosis of BN. She
comes to group one day and shares:
“On the weekend I went to a party with my girlfriend. It was
a party at some guy’s house in Cochrane. Neither one of us
knew him very well. We got really drunk and this guy
convinced us to go for a drive with him and some of his
friends. I must have been super drunk...I don’t remember
much but...I was raped. I can’t remember much but I know I
said no. I probably gave up or something. The thing I can’t
understand is why this keeps happening to me. This the
second time I’ve gotten so drunk that some strange guy has
had sex with me like that.”
Two Ideas
 What
happened
to you was awful
and totally unfair.
Sexual assault is
wrong and it isn’t
your fault.
 Something
about
your behaviour
needs to change.
“Why Does This Keep Happening to
Me?”
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The core message remains the same, sexual abuse is
wrong
Validate the feelings and provide the message that the
assault was wrong
What can the client control in this situation? The
drinking.
Can the conversation move to “creating a safe
relationship with alcohol” or “developing skills to
recognize risky situations”?
Move the conversation to a place exploring what the
client can control
Providing Education
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The “Triangle of
Violence”
The “Cycle of Violence”
Anti-violence activism
Questions & Comments
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[email protected]
Calgary Eating Disorder Program
403.955.7700