Disposition

1. 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

3. Disposition Background Method Treatment model Discussion Conclusion

4. Disposition Background Method Treatment model Discussion Conclusion

5. 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

6. Disposition Background Method Treatment model Discussion Conclusion

7. 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

8. The patient group • Most of the patients have posttraumatic stress disorder (PTSD). Comorbid diseases are eating disorders, depression, psychosomatic disorders and personality disorders

9. 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

10. Disposition Background Method Treatment model Discussion Conclusion

11. 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

12. 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

13. 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

14. Time schedule

15. 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

16. Window of tolerance Hyperarousal Hypervigilance Intrusive images and emotions Risktaking and selfdestructive behavior Panic and anxiety Windowoftolerance Feelingscan 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)

17. 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

18. Disposition Background Method Treatment model Discussion Conclusion

19. 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

20. 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 • Conflictsbetweengroupmembers

21. Disposition Background Method Treatment model Discussion Conclusion

22. 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

23. 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.

24. 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.