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

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Adapting IPT-G for Patients with Eating Problems
and Childhood Relational TraumaPsychologist
Juliane Monstad Therapist Kristian DirdalModum
Bad, Department for Trauma Treatment and
Interpersonal Therapy
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Disposition

• Background
• Method
• Treatment model
• Discussion
• Conclusion

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Disposition

• Background
• Method
• Treatment model
• Discussion
• Conclusion

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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/MacKenzies 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

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Disposition

• Background
• Method
• Treatment model
• Discussion
• Conclusion

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Treatment conditions

• 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

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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

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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

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Disposition

• Background
• Method
• Treatment model
• Discussion
• Conclusion

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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

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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

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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

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Time schedule
MON TUES WED THUR FRI
Process Group Psycho- education Outdoor activities until 13.00p.m Expressive therapy Group work on target and evaluation
Lunch Lunch Lunch Lunch
Physical activities Individual sessions Individual sessions Milieu/ large group Physical Activities Practical issues Social program at the ward
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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

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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 self- loathing
(Odgen Minton, 2000)
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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

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Disposition

• Background
• Method
• Treatment model
• Discussion
• Conclusion

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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

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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

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Disposition

• Background
• Method
• Treatment model
• Discussion
• Conclusion

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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

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References

• 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). Co-occurrence 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.