Transcript Lysbilde 1

Adapting IPT-G for Patients with Eating
Problems and Childhood Relational
Trauma
Psychologist Juliane Monstad
Therapist Kristian Dirdal
Modum Bad, Department for Trauma Treatment and Interpersonal Therapy
Disposition
Background
Method
Treatment model
Discussion
Conclusion
Disposition
Background
Method
Treatment model
Discussion
Conclusion
IPT-G history at Modum Bad
• Since 2002, IPT has been provided for groups with social phobia and
depression. The group modality has been based on
Wilfley/MacKenzie’s IPT-group manual (Wilfley et al., 2000)
• Childhood sexual abuse and avoidant personality disorder predicted
non-response course for patients with longstanding eating disorders
(Vrabel et al., 2010)
• High prevalence of childhood sexual abuse among patients with
eating disorders (Palmer et al., 1990)
• A new treatment was tailored to help patients with childhood
relational trauma (history of childhood neglect, violence and/or
sexual abuse), who, as a consequence, have trauma reactions and
eating problems as adults
Disposition
Background
Method
Treatment model
Discussion
Conclusion
Treatment conditions
Assessment
Phase 1
Home stay
Phase 2
4 days
10 weeks
3 months
6 weeks
One-year
follow-up
5 days
• The groups of patients (7 people) are in a closed group, where
•
about 80 % of the therapy is conducted in diverse group modalities.
We use out-door activities as an important part of the program
13 patients have completed phase 2, while 26 have finished phase
1. So far no patients have completed the one-year follow-up
The patient group
INCLUSION
EXCLUSION
Childhood relational trauma
Trauma symptoms
Eating problems
Motivation and suitability for group
therapy
Severe dissociative disorders
Psychosis
Severe addiction
BMI less than 17.0
Destabilized somatic conditions
Most of the patients have posttraumatic stress disorder (PTSD).
Comorbid diseases are eating disorders, depression, psychosomatic
disorders and personality disorders
Complex PTSD
• Besides symptoms of PTSD, the patients experience additional
problems:
– Affect dysregulation
– Dissociative symptoms, both mental and psychosomatic
– Negative self-perception (helplessness, shame, guilt and
self-blame)
– Interpersonal difficulties (fear and distrust)
– Somatization and medical problems
Disposition
Background
Method
Treatment model
Discussion
Conclusion
IPT-G adaptions for eating disorders
• Research supports an IPT effect on eating disorders (Agras et al.,
2000; Fairburn et al.,1995; Wilfley et al., 1993)
• IPT assumes that the development and maintenance of eating
disorders occurs in a social and interpersonal context, and
focuses on identifying and altering this context (Wilfley et al. 1993;
2000)
• The treatment model focuses on exploring how eating
difficulties are affected by challenges related to interaction with
other people, self-esteem and affect regulation
IPT-G adaption to PTSD
• Few studies report IPT for PTSD
• Some studies show that the IPT model is useful for treating
PTSD (Bleiberg og Markowitz, 2005; Ray og Webster, 2010 Krupnick et al., 2008)
• Chronicity of diagnosis
– Longer treatment period
– The treatment as a part of a longer treatment course
The new treatment model
• This model assumes that eating problems are strategies to regulate
painful emotions and need for control, developed through the
childhood relational traumas
• A main focus of the treatment is to help the patients understand
the development of their problems as a consequence of childhood
relational traumas
• Stabilizing trauma treatment is a central part of the model
• The goal is to help the patients feel more secure and increase
interpersonal functioning and affect regulation
• All the patients have interpersonal sensitivity as the main focus of
the therapeutic work
Time schedule
MON
TUES
WED
THUR
FRI
Process
Group
Psychoeducation
Outdoor
activities
until
13.00p.m
Expressive
therapy
Group
work on
target and
evaluation
Lunch
Lunch
Lunch
Lunch
Milieu/
large
group
Practical
issues
Individual
sessions
Physical
activities
Individual
sessions
Physical
Activities
Social
program at
the ward
Stabilizing trauma treatment
The psychoeducation group addresses topics such as:
• Coping with PTSD symptoms
• Affect regulation strategies
• Eating problems as affect regulation
In all groups and the milieu:
• Working with triggers
• Window of tolerance
Window of tolerance
Hyperarousal
Hypervigilance
Intrusive images and
emotions
Risktaking and
selfdestructive behavior
Panic and anxiety
Window of tolerance
Feelings can be tolerated
Able to think and feel
Hypoarousal
Flat affect, feeling numb
Cognitive functioning slowed
Feeling dead or empty
Feelings of shame and selfloathing
(Odgen & Minton, 2000)
Group work
• Active use of the supportive therapeutic factors to build a
cohesive group (universality, acceptance, altruism,
normalization, and hope)
Improve interpersonal functioning:
– Attachment
– Awareness of being safe
– Self-compassion
– Self-care
– Relational boundaries
– New relational experiences
Establishing treatment focus in the initial phase:
– Weekly goals and evaluation of these
– Working with here-and-now situations
Disposition
Background
Method
Treatment model
Discussion
Conclusion
Strengths of the treatment
Longer treatment periods in different phases:
• Opportunities to practice new skills in natural settings between
phase 1 and 2, and further develop this work in phase 2
• Integrating residential treatment in a community based treatment
Multiplicity of therapeutic factors (Hoffart, 2007)
• In groups, in the milieu, during home stay, etc.
Integrating therapeutic work with both eating problems and trauma
reactions
Challenges
• Symptoms vs. interpersonal focus
• Balancing stabilization (feeling secure) and interpersonal exposure
• Addressing eating difficulties
• Assessment and selection of patients
• Personality pathology
– Impulsivity, emotional instability, overlap of symptoms of
borderline personality disorder and Complex PTSD
– Conflicts between group members
Disposition
Background
Method
Treatment model
Discussion
Conclusion
Conclusion
• The treatment program is continually re-evaluated. The first 1 ½
years of the program show promising results for some of the
patients and less for others. Data from one-year follow-ups will give
further knowledge of treatment results
• The results suggest a decrease in depression
• The residential treatment gives certain results, but the patients’
complex problems demand treatment over a longer period
References
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Agras, W. S., Walsh, B. T., Fairburn, C. G., Wilson, G. T., & Kraemer, H. C.
(2000). A Multicenter Comparison of Cognitive-Behavioral Therapy and
Interpersonal Psychotherapy for Bulimia Nervosa. Archives of General
Psychiatry, 57 (5), 459-466.
Bleiberg, K. L., & Markowitz, J. C. (2005). A pilot study of interpersonal
psychotherapy for posttraumatic stress disorder. The American Journal of
Psychiatry, 162, 181-183.
Fairburn, C. G., Norman, P. A., Welch, S. L., O'Connor, M. E., Doll, H. A., &
Peveler, R. C. (1995). A Prospective Study of Outcome in Bulimia Nervosa and
the Long-term Effects of Three Psychological Treatments. Archives of General
Psychiatry, 52 (4), 304-312.
Herman, J. L. (1992). Trauma and recovery. New York: Basic Books.
Hoffart, A., Abrahamsen, G., Bonsaksen, T., Borge, F. M., Ramstad, R., &
Markowitz, J. C. (2007). A residential interpersonal treatment for social
phobia. New York: Nova Biomedical.
Krupnick, J. L., Green, B. L., Stockton, P., Miranda, J., Krause, E., & Mete, M.
(2008). Group interpersonal psychotherapy for low-income women with
posttraumatic stress disorder. Psychotherapy Research, 18 (5), 497 - 507.
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Ogden, P. & Minton, K. (2000). Sensorimotor psychotherapy: One method for
processing trauma. Traumathology, 6, 3.
Palmer, R. L., Oppenheimer, R., Dignon, A., Chaloner, D. A., & Howells, K. (1990).
Childhood sexual experience with adults reported by women with eating
disorders: an extended series. British Journal of Psychiatry, 156, 699-703.
Ray, R. D., & Webster, R. (2010). Group interpersonal therapy for veterans with
posttraumatic stress disorder: A pilot study. International Journal of Group
Psychotherapy, 60 (1), 131-140.
Vrabel, K. R., Hoffart, A., Rø, Ø., Martinsen, E. W., & Rosenvinge, J. H. (2010). Cooccurrence of avoidant personality disorder and child sexual abuse predicts poor
outcome in long-standing eating disorder. Journal of Abnormal Psychology, 119 (3),
623-629.
Wilfley, D. E., MacKenzie, K. R., Welch, R. R., Ayres, V. E., & Weissman, M. M.
(2000). Interpersonal Psychotherapy for Group. New York: Basic Books.
Wilfley, D. E., Agras, W. S., Telch, C. F., Rossiter, E. M., Schneider, J. A., Cole, A. G., et
al. (1993). Group cognitive-behavioral therapy and group interpersonal
psychotherapy for the nonpurging bulimic individual: a controlled comparison.
Journal of Consulting and Clinical Psychology, 61, 296-305.