Eating Disorders, Sexual Trauma and Group Therapy

1. Eating Disorders, Sexual Trauma and Group Therapy Lana Bentley MSW RSW. 03.28.09

2. Agenda • Definitions: eating disorders • Trauma • The research: is there a connection? • Group therapy: how does it look in practice?

3. Acronyms • AN: Anorexia Nervosa • BN: Bulimia Nervosa • EDNOS: Eating Disorder Not Otherwise Specified • CSA: Childhood Sexual Abuse • SA: Sexual Abuse • CEDP: Calgary Eating Disorder Program

4. Eating Disorders Defined DSM lV-TR

5. 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).

6. 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.

7. Bulimia Nervosa A. Recurrent episodes of binge eating. Binge eating is characterized by both: • 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 • 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 self-induced 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.

8. Eating Disorder Not Otherwise Specified • 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.

9. Children and Eating Disorders

10. Is it an Eating Disorder? • 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 • (Laske and Waugh, 2007)

11. 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

12. Trauma

13. 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)

14. Psychobiological Symptomology • Physiological Arousal • Most people who experience severe stress develop intrusive symptoms • Persistent intrusive symptoms leads to disordered pattern of arousal • Loss of Emotional Signals • 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)

15. Abnormal Reactions • 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)

16. What is Post Traumatic Stress Disorder?

17. Principles of Treatment • 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 re-establishing a feeling of integrity and control

18. Phases of Treatment • Stabilization • De-conditioning • Restructuring • Reestablishment of secure social connections • Accumulation of restitutive emotional experiences

19. Guidelines for Treatment • 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)

20. Client Population & Sexual Trauma The Calgary Eating Disorder Program

21. Background • 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 non-contact abuse) • Case managers differentiated between therapist-identified and client-identified abuse

22. Considerations • 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.

23. Key Terms: Contact Abuse • 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)

24. Key Terms: Non-Contact • 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)

25. Client Population

29. Considerations • 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”?

30. BREAK

31. What is the Link? Based on the work of Lisa Brown (1997)

32. Pseudo Control • 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

33. Punishment, Shame and Control • 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

34. Food and Abuse • 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)

35. What Does the Research Say? The Link Between Sexual Abuse and Eating Disorders

36. The Results are Mixed... • 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

37. Why are there Variations in the Research? • 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)

38. Variations Continued • 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)

39. Is there a Connection?

40. Definition: Mediating Factors - Drugs - Shame - Family Conflict - Personality Disorder Sexual Abuse Eating Disorder

41. Childhood Sexual Abuse and Bulimia: Mediating Role of Core Beliefs (Waller et. al) • 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

42. Childhood Sexual Abuse and Anorexia • 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

43. Patients with CSA history had greater psychiatric co-morbidity than patients without CSA • 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

44. Intrafamilial Sexual Assault • 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

45. Sexual Abuse and Purging (Perkins & Luster) • 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 • 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

46. Unwanted Sexual Experiences as a Predictor of Bulimic Eating Patterns (Casper & Lyubomirsky) • 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

47. Sexual Abuse, Substance Abuse, and Bulimia Nervosa • 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 BN-SDD reported sexual assault as did 23% of AN. Control group, 7%.

48. Group Therapy

49. Key Messages • “You are safe here” • “It was not your fault” • “Nobody deserves to be abused”

50. Is This the First Time They Have Talked about the Abuse? • 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?