**5. Modification of IPT-BN**

The IPT Team in Leicester (UK) adapted IPT-BN further by bringing back the original components of IPT (psycho-education, directive techniques, problem solving, modelling, role play and symptom review) and modifying the treatment for individual with BN where the eating disorders problems are taken into consideration. Although they have been using this model of treatment for BN for more than 15 years, only recently they have manualised it (Whight et al, 2010). This new modified version of IPT for BN is called IPT-BNm in this chapter to differentiate it from the IPT-BN developed by Fairburn.

IPT-BNm uses a time frame of 12-20 weekly sessions. The usual number of sessions is 16, which roughly breaks down into three areas: 4 assessment sessions, 10 middle sessions and 2 termination sessions. There is also a pre-treatment session (Session 0) where the patient

Interpersonal Problems in People with Bulimia Nervosa and the Role of Interpersonal Psychotherapy 7

world and expectations of treatment. He/She is also helping the patient to make links between their difficulties and their interpersonal issues. This can be difficult, particularly as

The patient needs to be actively involved in therapy throughout. The more they put into therapy the more they will get out of it. Initially the patient should be willing to share their difficulties and be able to listen to the therapist, working with them at making sense of the current difficulties and identifying realistic goals. The patient needs to be able to attend all planned sessions and to focus on any agreed tasks between sessions. Patients are also expected to track their symptoms each week and to bring to the session any relevant information about the agreed focus area. Changes in symptoms can often be markers of interpersonal events, so helping to link these changes to the agreed interpersonal focus area

The main task of session 4 is in helping the patient to choose a focus area to work on during the middle sessions of therapy. As in the original manual for IPT for depression, there are 4

 *Interpersonal Role Disputes:* Difficulties occur when the patient has non-reciprocal expectations from a significant other. This could be an overt or covert dispute and often there is a pattern of difficult relationships around the patient. It is important to focus on one key relationship that is current and where the patient feels that change is

 *Interpersonal Role Transitions:* Difficulties occur when the patient has difficulty adjusting or adapting to changes in their life. This could be changes at work, in living situation, in relationships, in financial status or any other area. What is key is that the patient has not adapted well to the changes and this is linked to their illness onset or deterioration. *Interpersonal Deficits:* Difficulties occur when patients had problems making or sustaining relationships with people. There are often repeated patterns of broken or failed relationships and the patient may be socially isolated. The patient may be highly sensitive to their difficulties so it can be very helpful to use role play in the session to

 *Complicated Bereavement:* Difficulties can occur when a patient is not able to resolve the death of a significant figure. This is often a partner or a family member, but can be the death of a friend or even a pet. The key feature is that the patient is not able to complete a grieving process and this impacts on their eating disorder and mood. The nature of the attachment with the deceased is an important consideration when considering grief

The task of the therapist is to find the most appropriate focus with their patient. All the information gained so far is assessed by the therapist, who by session 4 usually has an idea of what interpersonal issues are central to the patient's problems. IPT does not seek to understand the dynamics behind the eating disorder/depression but rather to help the patient make changes to their life now. The formulation for IPT is therefore simple, pragmatic and collaborative. Using the patient's words and a summary of the identified problem areas that have been highlighted over the previous 3 sessions, the therapist may

secrecy is so often an issue with patients with BN.

is an important skill for the patient to master.

**5.1.1.2 The role of the patient** 

**5.1.1.3 Interpersonal focus area** 

help them practice new skills.

suggest an area to focus on in therapy.

as a focus area.

clear focus areas:

possible.

and therapist agree goals for treatment and the model is explained. Therapy may be extended to up to 20 sessions if this is felt to be clinically appropriate, however this should be agreed with the patient close to the start of therapy and not towards the end of therapy as this can affect the potency of the termination sessions. The number of sessions may also be reduced if felt to be appropriate for the patient, but again should be agreed near the beginning of treatment.
