**5.1 Overview of IPT-BNm**

#### **5.1.1 Early sessions: sessions 0-4**

Broadly speaking the initial sessions are as detailed in the original IPT manual for depression (Klerman et al 1984) but specific for eating disorders. The aims of these sessions are to get a clear picture of the current problems along with a history of previous difficulties and interpersonal events. This enables the therapist and patient to identify areas of current difficulty, agree realistic treatment goals and to establish a focus for therapy. Areas for assessment include mood, interpersonal network, historical events (timeline) and eating disorder symptomatology. The main task of the therapist is to help the patient gain some understanding of the inter-relatedness of their presenting difficulties and to establish a specific focus for treatment dependent on their individual situation. As a part of this process and what makes this therapy specific for patients with BN is the use of psycho education related to eating. Throughout the therapy patients will be encouraged to complete food diaries that will be used to regulate patients eating. Psycho-education is a fundamental part of therapy.

By the end of session 4 the therapist will have a good understanding of whether or not the patient is able to work within the IPT model. The model is not suitable for everybody therefore if IPT is felt to be inappropriate other treatment options may be considered with the patient. IPT is primarily an outpatient treatment, but the early sessions could be started as an inpatient if needed, with the understanding that the patient would be discharged before treatment ended. This would enable them to practise skills between sessions and to build their interpersonal networks, which may be more difficult to achieve as an inpatient.

#### **5.1.1.1 The role of the therapist**

The therapist needs to engage the patient in therapy. A non-pejorative approach and an empathic understanding of the patient's distress can be crucial in gaining the trust – and therefore the commitment – of the patient. The therapist also needs to be clear about the boundaries of therapy. The sessions are weekly and commitment to regular sessions is an important part of therapy. Weekly therapy helps to maintain the intensity of the treatment whilst also giving the patient time to practice tasks between sessions. It is helpful to count down each session, letting the patient know where they are in therapy and how many sessions are left – for example "We are on session 2. We have 14 sessions left". This helps to start the process of termination but also emphasises the short-term nature of the therapy. This in turn acts as an incentive for the patient to make changes in therapy as they are aware of what time they have got from the beginning. It is also important for the therapist to stick to the boundaries of therapy – start on time, finish on time and always state the date and time of the next appointment at the end of each session. It can be very helpful to have the dates of all the sessions agreed as this avoids any confusion.

The role of the therapist in the early sessions is of active participation. The therapist is tasked to gather information on the patient's history, presenting problems, interpersonal 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 secrecy is so often an issue with patients with BN.

#### **5.1.1.2 The role of the patient**

6 New Insights into the Prevention and Treatment of Bulimia Nervosa

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

Broadly speaking the initial sessions are as detailed in the original IPT manual for depression (Klerman et al 1984) but specific for eating disorders. The aims of these sessions are to get a clear picture of the current problems along with a history of previous difficulties and interpersonal events. This enables the therapist and patient to identify areas of current difficulty, agree realistic treatment goals and to establish a focus for therapy. Areas for assessment include mood, interpersonal network, historical events (timeline) and eating disorder symptomatology. The main task of the therapist is to help the patient gain some understanding of the inter-relatedness of their presenting difficulties and to establish a specific focus for treatment dependent on their individual situation. As a part of this process and what makes this therapy specific for patients with BN is the use of psycho education related to eating. Throughout the therapy patients will be encouraged to complete food diaries that will be used to regulate patients eating. Psycho-education is a fundamental part

By the end of session 4 the therapist will have a good understanding of whether or not the patient is able to work within the IPT model. The model is not suitable for everybody therefore if IPT is felt to be inappropriate other treatment options may be considered with the patient. IPT is primarily an outpatient treatment, but the early sessions could be started as an inpatient if needed, with the understanding that the patient would be discharged before treatment ended. This would enable them to practise skills between sessions and to build their interpersonal networks, which may be more difficult to achieve as an inpatient.

The therapist needs to engage the patient in therapy. A non-pejorative approach and an empathic understanding of the patient's distress can be crucial in gaining the trust – and therefore the commitment – of the patient. The therapist also needs to be clear about the boundaries of therapy. The sessions are weekly and commitment to regular sessions is an important part of therapy. Weekly therapy helps to maintain the intensity of the treatment whilst also giving the patient time to practice tasks between sessions. It is helpful to count down each session, letting the patient know where they are in therapy and how many sessions are left – for example "We are on session 2. We have 14 sessions left". This helps to start the process of termination but also emphasises the short-term nature of the therapy. This in turn acts as an incentive for the patient to make changes in therapy as they are aware of what time they have got from the beginning. It is also important for the therapist to stick to the boundaries of therapy – start on time, finish on time and always state the date and time of the next appointment at the end of each session. It can be very helpful to have the

The role of the therapist in the early sessions is of active participation. The therapist is tasked to gather information on the patient's history, presenting problems, interpersonal

beginning of treatment.

of therapy.

**5.1 Overview of IPT-BNm** 

**5.1.1 Early sessions: sessions 0-4** 

**5.1.1.1 The role of the therapist** 

dates of all the sessions agreed as this avoids any confusion.

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 is an important skill for the patient to master.

## **5.1.1.3 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 clear focus areas:


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 suggest an area to focus on in therapy.

Interpersonal Problems in People with Bulimia Nervosa and the Role of Interpersonal Psychotherapy 9

interpersonal context and maintenance of the eating disorder. Perhaps this sets the ground for facilitating change and the setting of interpersonal goals can instill hope. Although the use of a case series was considered appropriate given the exploratory nature of the study, it is important to remember that these preliminary findings should be interpreted within the limitations of a case series design. Although there is incidental evidence from clinicians and patients of the effectiveness of this modified version of IPT for BN, there is a lack of research

In recent months, a new theoretical model of IPT for eating disorders has been proposed (Reiger et al., 2010). This model suggests that eating disorders are triggered by negative feedback regarding an individual's social worth due to its negative effect on self-esteem and associated mood. Eating disordered behaviours often begin because of this negative social evaluation, and over time such behaviours may become a more reliable source of self esteem and mood regulation than social interactions. The aim of IPT then is to help the patient to develop positive, healthy relationships, which replace the eating disorder in the attainment of positive esteem and affect. This newly proposed model also includes the monitoring of eating disorder symptoms and other elements, which were taken out of the original IPT-BN to make it comparable with CBT. However, this new therapeutic model has not yet been supported by empirical studies and does not differentiate between the treatment of anorexic

Interpersonal difficulties are both vulnerability factors and consequences of several psychiatric disorders, including Bulimia Nervosa. Over the last several years a growing number of research studies have demonstrated the efficacy of IPT as a treatment for several conditions. Within the field of eating disorders, IPT has been shown to be effective for patients with BN, although it appears to work slower than CBT. In order to make this treatment more effective several authors in different countries have modified this treatment further. In spite of the modification that IPT has gone through, the core elements of the therapy have been retained. Throughout IPT, therapists aim to help patients to identify the interpersonal difficulties maintaining the eating disorders symptoms in order to work through them. Although IPT has been used successfully over a number of years, research

We would like to acknowledge the IPT team in Leicester: Mrs Lesley McGrain, Ms Lesley

Agras, W.S., Walsh, T., Fairburn, C.G., Wilson, G.T., and Kraemer, H.C (2000) A multicenter

bulimia nervosa. *Archives of General Psychiatry*, 57, 5, 459-66

comparison of cognitive-behavioral therapy and interpersonal psychotherapy for

evidence which can only been achieved by a control Trial.

evidence for the new modified versions is still required.

Meadows, Dr Jonathan Baggott and Mr Chris Langham.

and bulimic disorders.

**8. Acknowledgement** 

**9. References** 

**7. Conclusion** 

**6. New modifications of IPT for patients with eating disorders** 

#### **5.1.2 Middle sessions: Sessions 5-14**

The middle sessions follow a similar format to each other, with the patient being asked to bring in their own material from the week to work within therapy. The therapist helps the patient to link the changes in the symptoms to the focus area, then works with the patient at active problem solving, contingency planning or practising new skills as appropriate.

The therapist maintains a hopeful and realistic stance on the patient's ability to make changes and to recover. All attempts at change should be praised as it can help to enhance the patient's feelings of self worth and their confidence at trying something new. It also helps to keep them engaged in therapy and to feel that the therapist is on their side working with them. This also needs to be balanced with the patient's capacity to change so it is important to be realistic.

All patients will have some difficulties with changing their way of eating, bingeing and vomiting. It is important to review the symptoms each week to maintain the focus and to identify change, but lack of change is also an issue. Some patients find it more difficult to make changes to their eating patterns and can really struggle to do things differently. It is part of the therapist's role to continue to encourage and support them whilst also being open and frank about change. Because the therapy is time limited this helps to motivate people to change, but lack of progress should not be ignored. Enquiring about what difficulties the patient is experiencing and helping them to develop problem-solving strategies to enhance their abilities to put therapy into practise can enable the patient to feel more attended to and can address feelings of having failed or worthlessness. As these can be key features of both eating disorders and depression they are important issues to address. Feeling attended to and supported can help the patient to stay engaged in therapy.

Half way through IPT (session 8) therapy is reviewed. This review is planned from the beginning. It is highlighted as a time to see how things have progressed thus far, ensuring that the right focus area is being worked on and allowing room for change if needed by the patient or the therapist.

#### **5.1.3 Termination sessions: 15-16**

The end of therapy should not come as a surprise to the patient; the therapist will have been counting down sessions and will have planned the dates of the final session with the patient. However it can still can come as a shock. The final 2 sessions are explicitly about ending therapy, about recognising and maintaining changes made, acknowledging that which has not changed and exploring feelings about ending. This can feel very positive for a patient who has recovered or more anxiety provoking for one who has not. It is important to end after the agreed number of sessions.

#### **5.2 Efficacy of IPT -BN(m)**

Arcelus et al (2009) conducted a case series evaluation of 59 patients and found that by the middle of therapy there had been a significant reduction in eating disordered cognitions and behaviours, alongside an improvement in interpersonal functioning and depressive symptoms. The authors found that although patients did improve significantly after eight sessions, their symptomatology did not continue to improve in the same way within the last eight sessions. This may suggest that there was something in the first sessions that facilitates change, which is lost in the last sessions. This could be explained by the impetus of the initial sessions; targeting symptoms, an opportunity to change and exploring the interpersonal context and maintenance of the eating disorder. Perhaps this sets the ground for facilitating change and the setting of interpersonal goals can instill hope. Although the use of a case series was considered appropriate given the exploratory nature of the study, it is important to remember that these preliminary findings should be interpreted within the limitations of a case series design. Although there is incidental evidence from clinicians and patients of the effectiveness of this modified version of IPT for BN, there is a lack of research evidence which can only been achieved by a control Trial.
