Friday, June 23, 1995

(!995) Therapist examines strategies for dealing with incest

Therapist examines strategies for dealing with incestBy Linda Bayer
Washington Jewish Week - June 23, 1995

When Cloe Madanes explained her revolutionary treatment for incest to a group of Israelis recently -- the perpetrator begs forgiveness on his knees before the victim -- an audience member said the technique would never work for Jews because they are forbidden to kneel.

On the contrary, Madanes replied. Maimonides made one exception to the prohibition against bowing down: when a person has sexually violated another.

Madanes, who related the story in a recent interview, says the Bible offers many such insights into the nature of sexual abuse.

For her new book, "Sex, Love and Violence; Strategies for Transformation," she began her research on incest, sexual violence and sadism by delving into Scripture. The result was a 16-step recovery program aimed at transforming violence back into love.

The strategy employs rituals for repentance and reparation that must precede forgiveness and psychological healing. Reminiscent of the Yom Kippur service that emphasizes slichah (pardon), tshuvah (return from sin) and tzedakah (charity to compensate for wrong-doing), she asks the perpetrator to offer money to the victim in addition to words of regret.

In the process, Madanes involves the extended family and ultimately the community in the healing process, calling upon the "tribe" to correct egregious assaults upon intimate relationships. She searches for strong members of the community to serve as protectors for victims of rape. Later, she brings the offender within the family back into a protective role.

In outlining these steps, Madanes has put together an optimistic book about what people can do to work through the often agonizing aftermath of sexual abuse.

In the process, she singles out the conflict between love and violence as the essential problem in life and the source of all therapy.

"People struggle for power over their own lives and the lives of others," she writes. "The wish to love and protect others is the highest human aim."

"Sex, Love, and Violence" connects the development of psychology to a decay among religious institutions during the 20th century. Madanes, co-director of the Family Therapy Institute of Washington, D.C., also criticizes psychology for separating morality from therapy.

Relating psychotherapy to mysticism, she says the practitioner must identify with the client's pain if treatment is to be successful.

Sometimes humor works well as a therapeutic tool. "Like a comedian, the optimistic therapist rises above the horror but never forgets it," Madanes writes.

In directing recovery from traumas like rape and incest, Madanes asks the entire family to kneel before the victim and apologize for not realizing what was happening or taking steps to protect the victim.

Later, the therapist meets alone with the victim and discusses how a person who has survived terrible violations can develop special qualities of compassion.

Not that Madanes confuses the issue of responsibility. In her view, perpetrators almost always claim to have been provoked, seeking to share blame with victims -- an approach she condemns.

However, Madanes also helps those who have been hurt to find ways to accept the past without denying their pain.

She notes that abusers were frequently attacked themselves as children and that the fathers of these assailants usually had sexual problems. Still, she does not excuse the rapist on these grounds.

According to Madanes, family members often reject her view that because a sexual assault targets a person's spirit, it is worse than a physical attack.

Yet when all other steps are complete, Madanes works to help offenders forgive themselves -- but not before amends have been made to victims.

In the book, she also deals with the violation of human rights in divorce cases, noting that it is "a woman's natural right to live with her children."

And she criticizes the destruction of a moral framework that results from the termination of parental rights, which she said often occurs in an arbitrary fashion in America.

In "Sex, Love, and Violence," Madanes confronts some of the most depraved aspects of human behavior without distraction or distortion.

Meanwhile, she musters the courage to hope for healing in situations that might easily elicit despair even among doctors exposed to all types of perversion.

Most touching are the transcripts of actual cases in which therapists make progress with offenders and families.

"Sex, Love, and Violence; Strategies for Transformation" by Cloe Madanes (256 pages, W.W. Norton & Company, $25.95).

Friday, June 02, 1995

T-shirt clothesline allows women to air the dirty laundry of abuse

T-shirt clothesline allows women to air the dirty laundry of abuse
By Lesley Pearl 
Jewish Bulletin of Northern California - June 2, 1995

"I survived attempted gang rape. I was 14 years old then. I'm now 45 years old and I can still see their faces. Still see them coming towards me. Still remember the fear. I survived that attempt. For 31 years I've been surviving it. My fear has turned to rage!...Today I live in Israel and the violence is the same."

A red Henley T-shirt carries the words, scrawled in black permanent marker. It hangs from two clothespins, surrounded by thousands of others declaring the pain of sexual abuse.

One is embroidered with rainbows, clouds and the Hebrew words for guilt, shame and fear of death. Another demands "Let The Woman Out" in red, green, blue and yellow, with black lines resembling prison bars overlapping the words.

The messages of these women -- 35,000 strong and from eight countries -- make up The Clothesline Project.

Begun in 1990 as a way to "raise awareness, express wounds and take out the dirty laundry," the Clothesline Project is a touring testament to survival.

A sample of shirts, about 6,000, came to Washington, D.C., earlier this year via garment bags and assistance from the Global Fund for Women. Nili Nimrod, director of the Association of Rape Crisis Centers in Israel, discussed the project in a talk last month at the Jewish Community Center of San Francisco.

Nimrod and the crisis center association go a long way toward dispelling fallacies about sexual abuse in both Israel and the United States -- among them, that "nice Jewish boys don't..."

"The myth that good Jews don't rape -- I can refute that right away," Nimrod said. "Most of the calls we get are from Jewish women who have been assaulted by Jewish men -- fathers, brothers, lawyers, bus drivers. The minority [of offenders are from] the Arab population.

"It's a global myth that assault [tends to] come from outside of your ethnic group."

What sets Israel apart from other countries, Nimrod said, is the way it handles sexual violence.

Like in America, it is rare for an offender to serve a full sentence, and government funding for education and services is limited at best. However, Israeli grass- roots efforts are making inroads in a relatively short amount of time.

In 1990, the Association of Rape Crisis Centers in Israel was established as the umbrella organization for seven organizations that provide crisis intervention, raise public awareness and lobby for improved law and policy.

The Clothesline Project is one of the ways the association educates about the problems of sexual abuse. Israel's government has responded favorably, Nimrod said, displaying the shirts at the Knesset in Jerusalem.

Other projects aimed at bringing sexual violence to the fore, and funded in part by the Global Fund for Women, include a documentary about incest, Yet a Child I Never Was.

Production, however, has stalled. Five women and one man were scheduled to tell their stories on film. Tragically, the man who had been assaulted by both his father and uncle in his youth committed suicide before filming began.

Nimrod pointed to this example as the value of the rape association for both men and women. Last year, Tel Aviv's newly created male victim hotline received more than 400 calls.

"The shame and guilt is the same for men as it is for women," Nimrod said. "But for men it becomes a question of sexual identity too. Did they provoke it? Are they gay? [they often wonder]"

According to Nimrod, 30 percent of last year's 5,000 calls logged were from incest survivors -- male and female. Determining whether sexual violence in Israel is on the rise or the decline, however, is more difficult.

"Every time there's an article about this or a well-publicized rape case we get an increase in calls. Part of this is greater awareness," Nimrod said.

"But we know that Israel is becoming a more violent society too," since the average age of offenders is dropping, she added.

"Most of the survivors we work with are Jewish women. But this isn't a Jewish problem or a women's problem. It's a social problem and a type of violence we need to end."

Thursday, June 01, 1995

Eating disorders among Jewish female adolescents in Israel: a 5-year study

Eating disorders among Jewish female adolescents in Israel: a 5-year study.
E. Mitrany,  F. Lubin, A Chetri and B Modan
Journal of  Adolescent Health - June 1995; 16(6): 454-7 

Department of Child and Adolescent Psychosomatic Medicine, Chaim Sheba Medical Center, Tel-Aviv University School of Medicine, Tel Hashomer, Israel.
PURPOSE: The current study examines the nationwide incidence of eating disorders (ED) among Jewish adolescents over a 5-year period (1989-93). METHODS: Data were obtained from 80% of all community and hospital adolescent and mental health institutions in Israel. Case identification was based on screening records according to DSM-III-R criteria for ED. RESULTS: Six hundred and thirty two new cases were identified with the following diagnostic distribution: anorexia 60%, bulimia 17%, anorexia and bulimia 4%, and ED not otherwise specified 20%. The present analysis is limited to females only (N = 602 or 95%). Median age for anorexia is 15 years and for bulimia 16 years. CONCLUSION: On the basis of this initial survey, the mean annual incidence of all eating disorders in Jewish Israeli females 12-18 years of age is 48.8 per 100,000. For anorexia the mean incidence is 29.0 and for bulimia 8.6. These figures represent an underestimation of the actual incidence due to incomplete data accrual.

Being Jewish in a Barbie world: Body-image negativism poses physical, mental threats to many women

Leni Reiss and Nadine Bonner 
Wisconsin Jewish Chronicle - June, 1995
In a Barbie world.... Stand in line at the supermarket, and you're bombarded by tabloids and women's magazines. "Lose 20 pounds in two weeks," screams one cover headline. Meanwhile, the cover photo is a four-layer chocolate cake offering "desserts to die for."
The tension between these two priorities - being thin and enjoying good food - has created an epidemic of eating disorders. Psychologist Stacey Nye, who specializes in treating those disorders, explains that "even though we're more educated about eating disorders now, it hasn't helped us protect ourselves from developing them, because we're seeing them in younger and younger children."
An additional conflict between Jewish culture, in which food plays a central role, and the general culture, which advocates the ideal of thinness, creates a compounded vulnerability for Jewish women, according to Nye. To explore these issues, Nye attended "Food, Body Image and Judaism - A Conference on Disorders and Resources for Change." The conference, held earlier this year in Philadelphia, was sponsored by the KOLOT Center for Jewish Women and Gender Studies at the Reconstructionist Rabbinical College and the Renfew Center, a women's psychiatric hospital in Philadelphia. It was sponsored in part by the Jewish Federation of Greater Philadelphia with support from the Germantown Jewish Center.
"I specialize in eating disorders and body image," explains Nye. "Being a Jewish woman myself, I wanted to learn more about what particular struggles (exist) for Jewish women. Jewish women have particular cultural vulnerabilities that make them more at risk."
Conference workshops included "Zaftig Women in a Barbie Doll Culture," "Chopped Liver and Chicken Soup: Soothing Food for the Traumatized Soul" and "Bagel Politics: Jewish Women, American Culture and Jewish Culture."
"If we want to follow our tradition, we have to revolve our lives around food," says Nye. "But if we want to assimilate, we have to look different."
Catherine Steiner-Adair, director of education, prevention and treatment at the Harvard Eating Disorders Center, points out that basic hereditary and physiological factors make it almost impossible for most women, including Jewish women, to conform to the Barbie-doll ideal.
"One percent of our population is genetically predisposed to be really tall, really thin and busty. And it's not us - it's the Scandinavians," says Steiner-Adair.
But experts note that societal and psychological influences make women strive to emulate unrealistic prototypes in terms of appearance.
"It's really hard not to buy into the general culture," admits Nye. "Girls are bombarded by messages that tell them appearance defines their identity. We have 8-year-old girls on diets. Body image dissatisfaction and distortion are rampant in our culture."
Steiner-Adair estimates that "every morning 80 percent of women wake up with body loathing. Eighty percent of the women in America don't relate to their bodies in a healthy, respectful, loving way."
"Stop worrying, and meet me at the water cooler"
She says that combining this general obsession with "weightism" and anti-Semitic stereotypes results in a greater vulnerability to eating disorders among Jewish women.
"If you have a Jewish girl who's feeling wobbly about herself and who feels a lot of pressure on her to assimilate, to achieve, it's very easy for a girl to say, 'I can't be all those things. I know what I'll be good at: I'll be thin,' " Steiner-Adair says.
Nye specializes in helping people accept their bodies and stop dieting.
"I help people to normalize their eating, not by dieting." She encourages her clients to eat normal, healthy food and to stop eating when they're full.
"I practice gentle nutrition, staying away from a dieting mentality." Nye also encourages increased activity rather than exercise, which she says has "a bad reputation with some people" - almost like medicine.
"I help people expand their identities. To explore what there is to feel good about," Nye adds.
Nye frequently speaks in schools to educate young people about accepting their own body image and that of others. "They're getting bombarded about looking a certain way. The reality is that not everyone is meant to be thin. Weight falls in a normal curve like anything else. Some people are intelligent, others are less intelligent. You can't make yourself taller."
She says one aspect in Jewish culture that is helpful is the emphasis on knowledge and excelling in scholastic settings, rather than on the athletic field.

Family plays a role
A Los Angeles-based psychotherapist who specializes in addictive behaviors, Judith Hodor finds, "more likely than not," that her patients with eating disorders come from Jewish homes. There often is an "enmeshment" in the Jewish family, she says, where one member, usually a child, feels pressured to be a reflection of the others.
"There is a tendency," she says, for parents to try to create a perfect existence as a positive reflection of themselves. This "demand for perfection" creates huge pressure on a child, who might try to starve herself as a "means of escape." This is one area, she explains, where the child can actually be in control.
Hodor cites an instance during a session in her office when the patient, a teenager, "actually was fading in and out due to lack of food" and the mother ran out to purchase milk, bananas and other edibles. "When she returned," Hodor recalls, "she looked at her daughter with tears in her eyes and said, 'You have to stop this. You are my reason for living.' "
"If I was anyone's reason for living, I might well want to disappear too," Hodor notes ruefully.
Within the context of the Jewish home, Hodor finds, there is an emphasis on intellectualism - and food. In other groups she tends to find "more aloofness, which, in a sense, protects family members from each other." But then again, she notes, they often have their own "isms, such as alcoholism" with which to deal.

Common to many cultures
Taking issue with the premise that eating disorders are more prevalent within Judaism, Phoenix psychiatrist Jill Zweig reports that a significant percentage of her patients who suffer from anorexia or bulimia are not Jewish.
"These ailments are pervasive in all cultures and all socio-economic levels," she finds. "Food plays an important role in the traditions of many cultures," she points out.
"Adolescence is a time of turmoil," Zweig says, "a time of seeking individuality and separation. This typically creates some conflict within the family and this is normal, expected - and to some extent, healthy."
But, she warns, those with eating disorders tend to internalize and distort suggestions that might be as innocuous as "cut down on junk food." Determining "what actually goes into the mouth" is one way that someone can be in total control. This can lead to such inappropriate thought and pattern behaviors as, for example, cutting out all junk food, all meat, all fats - "and then they are down to three rice cakes a day," Zweig says.
Individuals suffering from anorexia and bulimia constantly are thinking about food, Zweig says, and with both there is focus on body image as a source of self-esteem.
"The difference is how the individual goes about obtaining control. The anorexic constantly restricts food intake; the bulimic may binge, regularly or periodically, and then purge."
Parents who fear that their children may be prone to, or suffering from, an eating disorder should be alert to significant changes in their children's eating patterns, such as eliminating certain foods from their diet, skipping meals, finding excuses not to eat with the family; also, hair and/or weight loss, and cessation of menstruation are signals. Warning signs of purging include locking themselves in the bathroom after meals, along with the odor of vomit.
Patients prone to eating disorders are influenced by media-created images portraying the ideal woman along the lines of Ally McBeal, Zweig says, adding: "Dissatisfaction with their bodies comes down to a comparison with image. They look in the mirror and see their own body distorted. That is the illness part of it. They don't see what others see."
The challenge for parents, Zweig suggests, is to work on effective communication, "to go for realistic goal-setting."
To that end, she emphasizes the importance of tension-free family meals and the need to teach youngsters to make appropriate food choices.
"Fat-free items don't necessarily fall into that category," she says. "Rethink what has been drummed into us regarding the craze for fat-free foods," she proposes.
"The truth is that fat is necessary in moderation. The healthiest diets include some fat."
Both Hodor and Zweig advocate a team approach in their work with patients who have eating disorders. When appropriate, they confer and collaborate with dietitians, family physicians, gynecologists, family members and friends.
Nadine Bonner is a staff writer for the Wisconsin Jewish Chronicle in Milwaukee. Marilyn Silverstein of the Philadelphia Jewish Exponent also contributed to this story.

A Recovery Bill of Rights for Trauma Survivors

A Recovery Bill of Rights for Trauma Survivors
© (1995) Thomas V. Maguire, Ph.D.

As a matter of personal Authority, you have the right 
  1. to manage your life according to your own values and judgment.
  2. to direct your recovery, answerable to no one for your goals,
  3. to gather information to make intelligent decisions about
  4. your recovery. . . . . to seek help from a variety of sources, unhindered by demands for exclusivity.
  5. to decline help from anyone without having to justify the decision.
  6. to have faith in your powers of self-restoration and to seek allies who share that faith
  7. to trust allies in healing as much as any adult can trust another, but no more
  8. to be afraid and to avoid what frightens you
  9. to decide for yourself whether, when, and where to confront your fear.
  10. to learn by experimenting, that is, to make mistakes.
  11. For the preservation of personal Boundaries, you have the right
  12. to be touched only with your permission, and only in ways that are comfortable.
  13. to choose to speak or remain silent, about any topic and at any moment
  14. to choose to accept or decline feedback, suggestions, or interpretations
  15. to ask for help in healing, without having to accept help with work, play, or love. challenge any crossing of your boundaries.
  16. to take appropriate action to end any trespass that does not cease when challenged.
  17. In the sphere of personal Communication, you have the right
  18. to ask for explanation of communications you do not understand.
  19. to express a contrary view when you do understand and you disagree.
  20. to acknowledge your feelings, without having to justify them as assertions of fact or actions affecting others.
  21. to ask for changes when your needs are not being met
  22. to speak of your experience, with respect for your doubts and uncertainties.
  23. to resolve doubt without deferring to the views or wishes of anyone.
  24. Specific to the Domain of Psychotherapy, you have the right
  25. to hire a therapist or counselor as coach, not boss, of your recovery. receive expert and faithful assistance in healing from your therapist. be assured that your therapist will refuse to engage in any other relationship with you (business, social, or sexual) for life
  26. to be secure against revelation of anything you have disclosed to your therapist, unless a court of law commands it.
  27. to have your therapist's undivided loyalty in relation to any and all perpetrators, abusers, or oppressors.
  28. to receive informative answers to questions about your condition, your hopes for recovery, the goals and methods of treatment, and your therapist's qualifications. have a strong interest by your therapist in your safety, with a readiness to use all lawful means to neutralize an imminent threat to your life or that of someone else
  29. to have your therapist's commitment to you not depend on your "good behavior", unless criminal activity or ongoing threats to safety are involved
  30. to know reliably the times of sessions and of your therapist's availability ,including, if you so desire, a commitment to work together for a set term.
  31. to telephone your therapist between scheduled sessions, in urgent need, and have the call returned within a reasonable time. be taught skills that lessen the risk of retraumatization: (a) containment (reliable temporal/spatial boundaries for recovery work); (b) control of attention and imagery (through trance or other techniques); (c) systematic relaxation
  32. to reasonable physical comfort during sessions

Choosing Inpatient Treatment: When Good Choices Help and Bad Choices Hurt

Choosing Inpatient Treatment: When Good Choices Help and Bad Choices Hurt
Reprinted by Permission, © (1995) Nancy Shaufele, MS 

When Susan began having flashbacks of her traumatic childhood, she tried to handle them alone but soon became overwhelmed. In desperation she looked for psychiatric hospitals in the phone book and chose one with a big ad.

After verifying her insurance, hospital personnel whisked Susan away to a locked unit with psychotics, drug addicts, and worst of all, perpetrators. During the next few days she repeatedly begged for help with the flashbacks that continually plagued her. fortunately, Susan left the hospital before her insurance benefits were depleted; however she was afraid to seek other treatment.

How can you prevent yourself from having a situation like Susan's? This article contains some guidelines that can help you select inpatient care. Although it's important to seek the help of qualified professionals and referral services, the decision rests on you. Therefore, you need to become an informed consumer.

Understanding Your Needs.
There are two times when a survivor is most likely to consider inpatient treatment. The first is during a crisis period, when she/he is having trouble functioning in his/her life; safety and stabilization are the critical objectives of this type of stay.

The second occurs when a survivor has been in therapy awhile and feels blocked in his/her progress. He/She may choose to enter inpatient treatment to work intensely o specific issues for a limited time. This is most helpful when the survivor already has a good support system and a trusted therapist.

If you're questioning your need for hospitalization, it's important to know why you are thinking about inpatient care. Be as specific as possible. Ask for objective opinions from people you trust: your partner, therapist, and friends. You will need this information when you talk to an intake counselor.

Interviewing an inpatient facility is the same as interviewing a therapist. You are requesting specific services from qualified professionals. If you want your house painted, you interview painting contractors, ask about references, and sign a written contract. You must be at least as careful when you make mental health decisions, that can affect the rest of your life.

The Interview Process
Gather your referrals and begin the interview process. No matter how much you trust the person who gave you the referral, you need to conduct your own interview with each facility. After you complete every interview, take notes about it, including your feelings and impressions. Continue this process with each facility.

The process may seem daunting-- and can be. If inpatient care is a possibility in your recovery, you can empower yourself by making preliminary decisions now -- before you are unable to make them with the care and thoughtfulness they require.

In a crisis, you may not be able to make these decisions for yourself so it's important to have a trustworthy advocate. Select that person before you need them and educate them about selecting inpatient treatment.

There are two major considerations for inpatient care. The first is the program's credibility. You need to understand the quality and type of care you'll receive, as well as the training and experience level of the care provider.

The second consideration is financial. You need to know exactly what the program will charge you and how much of that charge your insurance will cover. Two ways to upset the stability you achieved in the hospital is to be discharged suddenly and/or receive a enormous bill that you cannot pay.

Here are something's to look for when interviewing an inpatient facility:
1. How many individuals and group sessions will you have? Who will lead them?
2. What specific programs will you be in?
3. What will your overall treatment plan be?
4. How much input will you have into your treatment plan?
5. How many survivors have they treated?
6. What programs do they offer specifically for survivors?
7. What credentials and training do the staff have in abuse issues?
8. What is the setting?
9. Is the facility locked or unlocked?
10. How long have they been operational?

1. What is the cost per day?
2. What specifically does that cost include?
3. What costs are not covered by your insurance?

1. How do they handle discharge planning?
2. How much input will you have into your discharge plan?
3. How can they help with your transition to home?
4. Do they offer aftercare resources?

Remember that inpatient care is a tool, not a cure. Many survivors receive treatment, only to feel disappointed when they return home and realize that their healing is not complete.

If you are gathering information now in preparation for possible future hospitalization, you don't need to reveal information to the hospital. Do not give them insurance information or let them pre-certify you for admission. If you are pre-certified at too many inpatient treatment facilities, you may trigger a red flag at your insurance company. At this point, all you have to say is, "I'm shopping, thanks".

Verifying Your Selection
Once you have narrowed your selection, and before you make a final decision, consult with a professional or counseling referral service. They may have updated information about the facility that you need to know.

The decision to seek inpatient treatment has the potential to be a life-saving, growth-enhancing process or another source of victimization. By making a thoughtful, well-informed decision, you can empower yourself and be a strong advocate of you own recovery.