Interpersonal Therapy for Bulimia Nervosa
Robin F. Apple
Stanford Medical Center
Department of Psychiatry
Interpersonal therapy (IPT) has been identified as an effective treatment
for bulimia nervosa that does not focus on bulimic symptoms. Rather, a
detailed assessment culminating in an "interpersonal inventory" identifies
core associated interpersonal problem(s) that become the focus of treat-
ment. For that reason, IPT may be particularly helpful for clients who have
become "stuck" in their eating disorder for reasons associated with prob-
lematic relationships.IPT is also helpful for clients who may benefit from a
therapy that offers some structure,focus, and containment without clear
behavioral directives. This article describes the theoretical background,
structure, and technical aspects of IPT and presents a bulimia nervosa
case in which IPT was used effectively,in part due to a "goodness of fit"
between the issues presented by this particular client and the treatment
model. The case also illustrates IPT's approach to handling resistance and
therapist/client relationship issues.
Since its debut as an option for treating bulimia nervosa,interpersonal therapy (IPT)
has been recognized as one of a handful of effective psychotherapies for this hard-to-treat eating disorder. Moreover,IPT compares favorably with the currently accepted "treatment of choice"–cognitive-behavioraltherapy (CBT)(Fairburn,1997; Fairburn, Jones,Peveler, Hope, & O'Connor,1993). Originally conceptualized forthe treatment of
depression (Klerman, Weissman, Rounsaville, & Chevron,1984),IPT has since undergone
subtle revisions that have facilitated its application to a wide variety of psychological
disorders such as panic disorder, somatization disorder, and a number of others.(For a
complete review, see Weissman & Markowitz,1994).
THEORY AND CONTENT OF IPT
As this article will discuss,IPT provides an alternative to treating bulimia nervosa that
does not focus directly on the eating disorder symptoms.Instead,through a comprehensive assessment of the client's history,it allows for identification of key "underlying"
problem areas that have contributed to the eating disorder overtime. The rationale of IPT
for bulimia suggests that those who develop the disorder typically exhibit a number of
interpersonal problems of which they may be unaware. These may include, among others:
conflict avoidance, difficulties with role expectations, confusion regarding needs for
closeness and distance, and deficits in social problem solving.
Frequently associated with these interpersonal problems are deficits in affect
regulation. Many bulimics describe a range of emotions including depression, anxiety, and
loneliness–which are commonly identified as binge triggers. Often through encouragement to work through the core interpersonal problem areas,IPT may also enable bulimics
to modulate the emotional states that perpetuate their eating-disordered behavior. The
time required for the therapy to effect changes in relationships and associated affects
might explain why IPT,in comparison with a more directive and symptom-focused treat-
ment like CBT,is slower to take action, but may reap benefits that are equally long lasting
(see Fairbum,1997.for a review).IPT is also an appealing choice for those who respond
more favorably to gentle encouragement or experimentation than to more directive behav-
IPT theory is based on the work of early interpersonalists such as Sullivan (1956).
The theory purports an association between certain broad interpersonal problem areas
(for example,role transition, grief,role disputes, and interpersonal deficits) and the devel-
opment, perpetuation, and exacerbation of a symptom or condition. Across disorders,IPT
has remained a time-limited (usually 24 to 36 weeks) and focused integration of com-
monly used techniques associated with other therapeutic approaches. These include open-
ended questioning,role plays, examination of advantages and disadvantages of change,
and encouraging expression of feelings.
IPT is both similar to and different from the theories and therapies from which it has
borrowed its techniques. For example, unlike psychodynamic therapies,IPT retains a
primary focus on "here and now" interpersonal relationship issues outside of the therapy
room. Past relationships are examined only to ascertain the origins of current problem
patterns in attitudes, expectations, communication, or behavior and the therapist-client
relationship is addressed sparingly. Unlike cognitive-behavioral therapies,IPT does not
include either systematic approaches to change problematic thoughts or beliefs or home-
work for practice and rehearsal of new skills.
STRUCTURE AND FORMAT OF IPT
IPT is conducted in three fairly distinct phases. The first phase, history-taking and assess-
ment,lasts between three and five sessions. The objectives of this phase include identi-
fying the primary problem area(s) to be addressed and introducing clients to an
interpersonal rationale for understanding their eating problems.Initially, a thorough review of
the patient's current relationships (for instance, number,type, quality, and degree of
reciprocity) sheds light on the current issues linked to the disordered eating behaviors.
Then,to establish associations between the onset and exacerbation of the symptoms
overtime,four areas are traced chronologically from the client's earliest memories to the
(i) significant life events,(ii) mood and self-esteem,(iii)interpersonal relationships, and
(iv) changes in weight. From the review of current and past relationships and experi-
ences,the client creates an interpersonal inventory or "life chart" that usually provides a
clear illustration of the nature of interrelationships between certain life experiences and
bulimic symptoms. As these associations are made clear, clients can begin to consider the
role of underlying issues in determining the course of their eating disorder and under-
stand more clearly the rationale of IPT. Once the life chart is completed,the therapist and
client conclude the assessment phase by coming to an agreement about the primary prob-
lem area(s) to be addressed for the remainder of treatment.
As described above,IPT specifies four general problem areas that comprise the range
faced by most individuals requesting psychotherapy:role transition,interpersonal role
disputes, grief, and interpersonal deficits. Based on the assessment, one or more catego-
ries are chosen as the primary treatment focus. The categories are broad and flexible so
that therapists can devise an individualized formulation for each client. Therapy goals,
and to some extent techniques, are determined by the problem area(s) identified as pri-
mary. For example, a focus on successfully navigating a role transition (for example,
moving away from home to start college) would entail helping a client to: clarify the
meaning of the transition;identify the advantages, disadvantages, and perceived obsta-
cles to navigating the transition; express feelings about moving from the old to the new
role; anticipate and practice skills and establish necessary supports. Klerman et al.(1984)
present a complete description of problem areas,therapy goals, and techniques.
Once the assessment phase is concluded,the middle phase of therapy begins with the
therapist "steering from behind" as the client initiates discussion of material related to the
agreed-upon problem area(s). The goals during this phase are particular to the identified
problem areas. For example, a few of the goals of therapy when role transition is a
primary problem include exploring the meaning of moving from one role to another,
expressing the associated affects such as grief, anxiety, or excitement, and developing the
skills and supports required in the new role.In IPT,the client is encouraged to avoid
detailed discussion of eating behaviors in favor of exploring the interpersonal context in
which they occur. Prolonged discussion of symptoms is viewed as potentially distracting.
The final phase of treatment involves summarizing and consolidating gains, anticipating
future problem areas, and thinking through solutions. At the end of treatment, clients are
encouraged to discuss specific changes in their eating behaviors, particularly as they
relate to improvements in relationship patterns.
The case that will be presented here was based on a manualized from of IPT for
bulimia nervosa, developed for a multicenter bulimia nervosa treatment study comparing
IPT and CBT (see Fairbum,1993). Some modifications were made to adapt IPT for
treatment of bulimia nervosa; others were designed to enable clearer comparisons with
CBT in this study. First,the assessment phase included a history of eating disorder symp-
toms and changes in weight. Second, after completion of the assessment phase, every
therapy session concluded with a nonspecific recommendation for change,for example:
"If you find an opportunity to work on issue X during the week,feel free to take it."
Third,the treatment format consisted of 19 sessions over 20 weeks (twice weekly for two
weeks, weekly for12 weeks, and biweekly for three weeks). Finally attempts were made
to limit patients' discussion of their disordered eating behaviors to 10 seconds or less.