Interpersonal Psychotherapy (IPT) for Eating Disorders

IPT is a time-limited, collaborative, and empirically validated therapy used to support people with mood disorders and eating disorders. It focuses on the way common life events, including loss, change, and conflict in close relationships, affect mental health.

Relationship difficulties are viewed as contributing to mental health difficulties (such as eating disorder behaviours), which in turn contribute to relationship difficulties. Essentially it sees the eating disorder (ED) as primarily a coping strategy for dealing with relationship difficulties, loneliness, loss, stress of change etc.

The goal of IPT is to ease the eating disorder by improving relationships and social connection. It uses skills and strategies to help clients to:

• Repair or build supports
• Improve communication
• Resolve relationship difficulties

The Development of Interpersonal Psychotherapy

Interpersonal Psychotherapy was first published in 1984 and is based on three theories:

1. Adolf Meyer’s theory that behaviours associated with mental health difficulties can be viewed as coping strategies for difficulties with relationships
2. Harry Stack Sullivan’s theory that people’s coping strategies tend to be long-term patterns that show up in significant relationships
3. John Bowlby’s theory that early attachment plays an important role in later relationships and mental health

Interpersonal Psychotherapy Perspective on Eating Disorders and Mood Disorders

IPT proposes: 

• That the development and maintenance of eating disorders and mood disorders occurs in a social context
• Both the maintenance of the ED and the response to therapy are influenced by the relationships between the person and their significant others
• The eating difficulties/mood disorder can be shifted by identifying and altering relationship difficulties

IPT views self-harm, suicidality, and alcohol and drug dependence all through the same lens - a coping strategy that both results from relationship difficulties and contributes to relationship difficulties. 

In contrast to Cognitive Behaviour Therapy (CBT), it is not trying to create change through challenging distressing thoughts and shifting eating disorder behaviours, but through improving the quality of significant relationships.

IPT groups life difficulties into four problem areas in relationships:

1. Role Transitions - changes that occur moving from one social role to the next eg. moving from high school to university
2. Role Disputes - situations in which a person and at least one significant other have nonreciprocal expectations about the relationship eg. an adolescent child developing identity separate to that of their parents, increasing their autonomy, and becoming body aware
3. Grief - loss of a loved one or loss of something else significant eg. going from able-bodied to disabled, or developing a chronic health condition (and therefore going through a role transition)
4. Interpersonal Sensitivities - social isolation, ongoing unfulfilling relationships, difficulties forming meaningful relationships, or difficulties having sustained long-lasting relationships

Interpersonal Psychotherapy Structure

IPT is a structured, manualised therapy that has three phases.

1. Initial/assessment phase
2. Intermediate phase
3. Conclusion and maintenance phase

Phase one includes:

• Assessment and diagnosis
• Psychoeducation around the eating disorder
• Acknowledging that eating disorders are serious, are not the client’s fault, and take a lot of work and effort to change
• Work on the client-therapist relationship
• Developing the interpersonal inventory (see below)
• Establish problem area
• Therapist discusses with the client the importance of engagement and reassures them that change is possible

The Interpersonal Inventory can occur over multiple sessions and is a key ingredient in IPT. It is a timeline of events (both positive and negative) and in particular is interested in looking at times when the eating disorder was easier or harder, and what was happening socially/relationally for the client at that time. 

In a nutshell, it explores the connection between interpersonal difficulties, trauma, and stressful life events, with the onset and maintenance of the eating disorder.

Phase two takes up the majority of the sessions, and is a practical, goal oriented phase, where each week the therapist discusses with the client how skilful and satisfied they feel in their significant relationships and social groups.

Rather than focusing on eating disorder behaviours, the focus is mostly on satisfaction in relationships and social life, and how this makes the eating disorder better or worse. 

Phase two will often include:

• Goal setting
• Identifying dissatisfaction in relationships
• Skills to make and maintain friendships
• Skills to improve relationships
• Skills to cope with or reduce loneliness
• Work around accepting and tolerating difficult emotions
• Identifying ways in which the eating disorder is connected to interpersonal difficulties 

During phase two the client is expected and encouraged to actively work on goals between sessions.

In phase three the therapist and client review the course of therapy, what has changed, and what support might be needed in future. The next steps may be:

• Finishing therapy
• Maintenance sessions at a reduced frequency
• Moving to a different therapy model 

The IPT perspective is that if the eating disorder hasn’t eased significantly, that reflects the limits of the therapy, not a failing of the client. The therapist may recommend alternative therapies, or may also identify interpersonal issues that have not been adequately addressed.

Strengths and Limitations

Strengths

• Time-limited
• If IPT works as intended, then it can result in better relationships and improved social skills. This improves the client’s quality of life in ways beyond easing the eating disorder 
• It is evidence based
• Is less complex than other therapies. IPT doesn’t involve trying to change thought patterns or unhelpful thinking, as cognitive behavioural therapy does. Instead, IPT adopts a less complex approach, and focuses on changing relationship patterns. For many people, this can be what drives their mental health difficulties
• Is an approved therapy for Bulimia Nervosa (BN) and Binge Eating Disorder (BED) under Medicare’s Eating Disorder Plan (EDP)

Limitations 

• IPT is purely focused on the present-day. While discussions about past relationship difficulties will take place, the focus is very much on the “here and now”. While this won’t matter for some people, this is generally not a good fit for people with trauma
• It requires active commitment. In order for IPT to truly work, a person needs to actively commit to the therapy, and be ready to put into practice what they learn. When someone is feeling very low, it can be hard to commit to something like this.
• It may not suit more severe and complex presentations, and tends to be more helpful when difficulties are mild to moderate
• The shorter timeline tends not to be a good fit for people with long-standing difficulties
• It is not an approved therapy for Anorexia Nervosa (AN) or Other Specified Feeding or Eating Disorder (OSFED) under Medicare’s EDP