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Adolescence may be seen as 'a discrete and significantly different stage from that of childhood or adulthood' (Needham 2000). It is a time of great emotional, social and physical upheaval and while a good number of young people weather the change with little disturbance, others have a more problematic time. It is a time of changing relationship, exploring new values and a period in which they are preparing for major choices in their life in terms of deciding on a career or leaving home for the first time.
Growth work in adolescence involves the development of self esteem, the establishment of identity and psychological disengagement from family. These are identified precursors to the development of eating disorders. A range of interventions has been demonstrated to be of value in the treatment of eating disorders as well as underlying psychological problems such as anxiety and depression, and these may be augmented by the use of hypnosis. Evidence for this is presented in this article, following an introduction to eating disorders, which affect one per cent of all young women in the UK.
Bruch (1973) argues that this would explain why anorexia, for example, so typically emerges in adolescence -- a period during which the development of autonomy, mastery and competence is crucial in attaining maturity and gaining independence from parents. In a number of studies quoted by Abraham and Llewellyn-Jones (2001) it would seem that over-perception of body size among adolescents is a global problem, particularly in the western world.
Overweight and obese adolescents are particularly vulnerable to low self esteem, which has an effect on their performance at school and personal relationships. Many adolescents feel that their changing body is out of control. Unfortunately this 'out of control' feeling and alterations of body size and shape can result in eating disorders linked with the young person's refusal to grow up and accept her or his developing body shape. Young people with these disorders are known to present with a number of personality disorders as well as having a high incidence of coexisting psychiatric conditions, specifically mood disturbances, major depressions and obsessive compulsive disorders. In addition, they suffer from feelings of inadequacy, lack self confidence, have poor self esteem and poor coping mechanisms.
• a refusal to maintain normal body weight
Treatment of this condition is far from simple and requires a long-term commitment from the patient and the family.
• recurrent episodes of binge eating
Coman (1992) highlighted the personal characteristics of bulimic patients as having feelings of shame, self criticism, immediate gratification needs, and a strong need for approval and heightened interpersonal sensitivity.
Whether obesity is an eating disorder is open to debate. In the 1970s and 1980s it was noted that many obese people eat normally and obesity was defined as a medical rather than a psychological disorder. However, it became clear during the 1990s that a subgroup of obese individuals, and some of normal size, have a pattern of episodic binge eating that is similar to people with bulimia nervosa.
People who binge eat are not suffering from anorexia nervosa, since their body mass index (BMI) is more than 17.5; nor do they have bulimia nervosa, since they do not use dangerous methods of weight control such as purging or vomiting on a regular basis. It appears that binge eaters use food to regulate mood or difficult emotions, particularly sadness, anger and feelings of inadequacy (Telch and Agras 1996).
Binge eating episodes are associated with at least three of the following:
• rapid eating
The overall aim of treatment is not necessarily to cure the condition but to control it, since the eradication of all eating disordered behaviors is unrealistic and the goal of therapy is the maintenance of healthy, controlled eating patterns (Coman 1992).
Techniques used in treating eating disorders aim to restore normal eating behaviors. Behavioral approaches alone or combined cognitive behavior therapy may be used. Behavioral techniques might include simply not buying trigger foods or avoiding certain shops; that is, building up new habits to replace existing ones. Another example would be modifying eating behavior such as eating in the same place each day, or concentrating solely on eating and not watching television at the same time.
Eating behaviors are learned behaviors therefore they can be unlearned, although this can take some time. Rehearsal, age progression or assertiveness training may be used. Control of binge eating may include eating regular meals, avoiding addictive foods, instigating a controlled binge and delaying tactics.
Using hypnosis in treatment
Heap (2002) cautioned that uncovering distressing material during these sessions may be particularly difficult for depressed patients who will make up a significant portion of this group. Hypnosis may also be used to help patients develop feelings of control and mastery over their thoughts and behaviors. Cognitive and behavioral techniques for weight management have increased efficacy when combined with ego strengthening, imagery, systematic desensitisation, and cognitive restructuring (Fairburn 1985, Gross 1992, Hartland 1966, Heap (2002), Vandenlinden and Vandereycken 1990). Coman (1992) has suggested that, because of the need for control within this patient group, the use of indirect and permissive suggestions for trance are more effective since they serve to enhance rather than challenge the patient's need for control.
One example is Alladin's (1992) disassociative theory of depression, which concentrates on the behavioral aspects of depression rather than the feelings of depression. Alladin seeks to identify what it is in the client's behavioral repertoire that initiates the feelings of depression. He then seeks to change the precipitating behavior. Intervention involves four sessions of routine cognitive therapy, with hypnosis introduced in the fifth session.
Techniques include rehearsal with cognitive restructuring, ego strengthening, age progression and post-hypnotic suggestions, as well as assertiveness training. Depressed patients, however, may respond less well to the traditional hypnotic inductions emphasising as they do, a relaxed, more passive effect which may be counter-productive in patients who are already passive. Therefore the use of the active alert method may be more appropriate, as described by Banyai et al (1993).
The use of hypnosis as a preventative intervention has not been assessed. It is suggested that it could be directed, not overtly at addressing eating disorders, but to address the underlying aetiology, for example anxiety, control, self esteem, assertiveness and identity development.