Interpersonal Psychotherapy for Bulimia Nervosa
Amy H. Olson, LCSW
Many psychotherapies are interpersonal in nature, however, Interpersonal Psychotherapy
has clearly defined components proven effective in the treatment of disordered eating.
Originally developed in the 1960’s as a treatment for depression, the model has been adapted
to treat many types of mood and anxiety disorders. This paper will focus on the adaptation
called Interpersonal Psychotherapy for Bulimia Nervosa (IPT-BN). To be highlighted in this
paper are the rational and efficacy of IPT-BN as well as its focus on breaking treatment into
stages and specifically focused problem areas.
One of the most striking features of IPT-BN is the philosophy to focus on the interpersonal
context in which eating problems occur, rather than the eating problems per se. Patients who
focus on symptoms are encouraged to shift “from their symptoms to addressing current life
situation, stressors, and interpersonal reactions” (Weissman, Markowitz & Klerman, 2000, p.
318). Because this approach can feel counterintuitive for the bulimic, who is often quite
symptom focused, the rationale must be clear and reiterated as necessary.
Rationale for IPT-BN
Episodes of bingeing and purging are influenced by situations that are interpersonal in
nature, such as feeling vulnerable, embarrassed, angry or lonely. Although patients are not
necessarily aware of their interpersonal problems, due to the distracting nature of symptoms,
such problems serve to perpetuate and maintain the disorder. IPT seeks to resolve the
underlying interpersonal problems and therefore resolve the eating disorder behaviors. It is
explained upfront that there will be little focus on symptoms outside of initial sessions, and
when it becomes a source of frustration for the patient, the rational is once again made clear.
Efficacy of IPT-BN
In contrast to IPT-BN, Cognitive Behavioral Therapy (CBT) is a favored treatment for BN that,
“…operates directly on the disturbed eating habits and attitudes.” (Fairburn, 1997, p. 291).
IPT-BN has been measured against CBT since the 1980’s with very good outcome. Studies at
Oxford University (Fairburn, p. 278) have shown IPT-BN to assist substantial decline in eating
disorder behavior. CBT achieves effects more quickly than IPT-BN, but at 12-month follow-up
both therapies are shown to maintain gains. Fairburn states, “… short-term psychotherapies
that focus on modifying current interpersonal problems are a promising alternative to CBT. IPT
is the leading treatment of this kind” (p. 281).
Further studies have replicated these results, finding at 8-12 month follow-up “no statistically
significant differences in outcome” between CBT and IPT-BN (Weissman, Markowitz &
Klerman, p. 322). Because evidence for IPT is young, and it’s tendency to produce positive
effects more slowly, CBT may still be recommended as a first line treatment for BN. However,
based on findings thus far, Garner and Needleman (1997) assert that an argument can be
made for using IPT-BN as a first line treatment because of similar long-term outcomes, and
that any therapist well versed in the IPT model should not feel pressure to abandon it in favor
of CBT.
Stages of Treatment
IPT-BN, in its pure form, is a short-term focal therapy, lasting approximately 15-20 sessions
over a period of 4-5 months and broken into three stages:
Stage One introduces the patient to IPT-BN, helps determine what kinds of interpersonal
problems they have, and which of the four problem areas (below) will be the focus of
treatment. During this stage the therapist is directive in reviewing past and present
relationships, evaluating interpersonal functioning and determining the interpersonal context in
which disturbed eating behaviors take place. In Stage Two, areas for psychotherapeutic work
have been identified, and the patient is encouraged to become her own change agent by
taking the lead in sessions. The role of the therapist is to keep the interpersonal focus of the
work, redirecting symptom focused talk and stressing change. Stage Three marks the
termination phase of treatment where changes made are reviewed and planning for relapse
prevention takes place. Patients are not necessarily symptom free at termination. Full benefits
of IPT-BN are often not felt until several months after termination, and patients are encouraged
to maintain positive changes on their own for a while before re-engaging in any treatment.
Four Problem Areas
As described above in Stage One, patients are helped to determine, out of four problem
areas, which are troublesome, and which will be the focus of treatment. The four problem
areas include grief, interpersonal role disputes, role transitions and interpersonal deficits.
The first problem area, grief, has not been noted by Fairburn to be very common in women
with BN, but if it is present it is recommended that it be dealt with first, as it is one of the easier
problem areas to resolve. In IPT the term grief is reserved only for the death of a loved one –
other losses are attended to under role transitions. Goals in this problem area are to facilitate
mourning and the rebuilding of interests and relationships.
The second problem area, interpersonal role disputes are quite common for women with BN
(Fairburn). “An interpersonal dispute is a situation in which a patient and at least one
significant other person have nonreciprocal expectations about their relationship” (Weissman,
Markowitz & Klerman, p. 75). Goals in this area include identification of the dispute,
modifications of expectations or communication and either re-negotiation of the relationship or
dissolution. When appropriate, significant others may be brought into treatment to address the
role dispute.
Role transitions are the third problem area and are also fairly common for patients with
eating disorders. Problems in this area encompass difficulty with life’s changes and the
necessity of balancing multiple roles. Patients who experience difficulty with role transitions
generally view changes such as individuating from parents, leaving school, marriage or
becoming a parent as losses (Weissman, Markowitz & Klerman). Goals in this area include
expressing feelings about giving up old roles and acquiring skills and supports necessary to
adapt to the new roles.
Interpersonal deficits, the fourth problem area, found less commonly by Fairburn, exist when
one has a long history of difficulty initiating or sustaining lasting relationships and have,
“…pervasive feelings of loneliness and social isolation not directly related to recent transitions
or role disputes” (Weissman, Markowitz & Klerman, p. 103). Also included are any pervasive
patterns of relating that contribute to failed relationships. This is the most difficult problem area
to treat, and if any other problems exist in the areas of grief, interpersonal disputes or role
transitions, they should be treated first. Treatment of interpersonal deficits does not lend itself
well to a brief treatment model, and changes in that area should be considered “good
beginnings”. Primary goals include reducing social isolation and creating less intense but
satisfying relationships.
Problems with IPT-BN
As with all psychotherapeutic models there are strengths and weaknesses, IPT no exception.
One element that serves as both a strength and a weakness is the time limited nature. Many
patients benefit from the focal basis as well as the gentle pressure to change with 20 sessions
or fewer. However, for patients with interpersonal deficits, particularly personality disorders,
longer psychodynamic therapy is usually necessary.
Dennis and Sansone (1997) highlight the importance of the therapist distinguishing between
personality traits, “ingrained and habitual patterns of psychological functioning”, and
personality states, “ reactions to stressful situations that tend to be transient or brief in
duration, or that subside shortly after these conditions are removed” (p. 437). IPT-BN may be
better suited for those patients experiencing problems with personality states.
Fortunately, the outpatient clinician is advised to use an integrated approach to patient care,
using the least invasive treatments initially, and adding in longer-term therapies such as
psychodynamic, expressive and pharmacotherapy as needed if the patient has not responded
to IPT-BN.
Resources
Dennis, A.B. & Sansone, R.A. (1997) Treatment of patients with personality disorders. In D.M.
Garner & P.E. Garfinkle (Eds.) Handbook of Treatment for Eating Disorders (2nd ed.) (pp. 437-
449). New York: The Guilford Press
Fairburn, C.G. (1997) Interpersonal psychotherapy for bulimia nervosa. In D.M. Garner & P.
E. Garfinkle (Eds.) Handbook of Treatment for Eating Disorders (2nd ed.) (pp. 278-294). New
York: The Guilford Press.
Garner, D.M. & Needleman, L.D. (1997) Sequencing and Integration of treatments. In D.M.
Garner & P.E. Garfinkle (Eds.) Handbook of Treatment for Eating Disorders (2nd ed.) (pp. 50-
63). New York: The Guilford Press
Weissman, M.M., Markowitz, J.C. & Klerman, G.L. (2000). Comprehensive Guide to
Interpersonal Psychotherapy. Basic Books.