Interpersonal Psychotherapy (IPT) for Eating Disorders

Core Components

Interpersonal psychotherapy (IPT) is a time-limited psychological intervention, originally developed for the treatment of depression, but subsequently adapted for the treatment of eating disorders including Binge Eating Disorder, Bulimia Nervosa, Anorexia Nervosa and Other Specified Feeding and Eating Disorders (OSFED). This attachment-based intervention focuses on addressing ‘here and now’ interpersonal relationships by working on one of four interpersonal focal areas (grief, role dispute, role transition and interpersonal sensitivities).  IPT was based on the fundamental principle that there is a reciprocal relationships between life events and depression (or other mental health presentations) e.g. that while life events affect depression, depression can also affect interpersonal relationships. The dual goals of IPT are to improve interpersonal functioning and to reduce mental health symptomatology. IPT has four key features that help achieve its treatment goals. These include:

1. A “here and now” focus, specifically on interpersonal relationships and social support. IPT recognises the contribution of interpersonal difficulties to the onset and maintenance of psychological distress and mental health disorders. It therefore targets a current interpersonal issue related to the maintenance of a mental health difficulty by building on communication and interpersonal skills, and strengthening an individual’s social network so that they can mobilise social support in times of interpersonal distress. IPT is an affect-based therapy. It focuses on the identification and validation of affect, with the aim of improving communication of emotions to others.
2. Based on biopsychosocial/cultural/ spiritual model formulation: IPT conceptualises an individual’s experience and presentation in the context of biological factors (e.g. genetics and physiology); social factors (e.g. social relationships and support); psychological factors (e.g. disposition and attachment style); cultural factors; and spiritual factors. IPT acknowledges that mental health difficulties are determined by a range of different factors, however the experience of mental health difficulties themselves impair an individual’s motivation towards, participation in, and experience of interpersonal relationships. Therefore, the core premise of IPT is that by resolving interpersonal maintaining factors contributing to an individual’s distress, or enhancing supportive relationships that mental health difficulties will improve.
3. Time limited: In the acute phase, IPT for eating disorders is typically delivered over 16 weekly sessions, with the potential of maintenance sessions post therapy to support ongoing symptom remission.
4. A non-transferential approach: IPT’s key focus is on relationships that are outside of the patient-therapist relationship. Transference, which ensues during therapy, provides the therapist with key information about an individual’s communication and expectations of relationships. The patient-therapist relationship is not the focus of IPT; however this platform enables the therapist to hypothesise about interpersonal functioning outside of therapy, and can support tentative interpersonal feedback with the aim of seeking parallels in interpersonal relationships outside of therapy.

IPT sessions are typically delivered weekly, with each session lasting about 45-50 minutes. These sessions are delivered in three phases:

1. Initial phase: Delivered over sessions 1-4 and includes assessing the presenting problems, providing psychoeducation about presenting symptoms, introducing the recovery role, creating a timeline and conducting an interpersonal inventory. The initial phase will culminate in the development of an interpersonal formulation in which the focal area is identified and agreed and further IPT sessions are contracted.
2. Middle phase: Delivered over sessions 5-12 and aims to resolve the interpersonal problem aligned with one of four IPT focal areas.
3. Final phase: Delivered over sessions 13-16 and aims to bring a good conclusion to the treatment

Rieger and colleagues (2010) proposed a theoretical model of IPT for eating disorders (1).  They state that difficulties with interpersonal relationships and associated negative social evaluation are thought to trigger poor self-esteem and negative affect, which in turn precipitates eating disorder symptomatology.  The authors propose that disordered eating behaviours may be perceived by an individual to be a more effective strategy to improve self-esteem and support emotion regulation than those provided via interpersonal interactions.  However, instead the presence of an eating disorder is hypothesised to further disrupt social relationships, leading to a negative feedback cycle which maintains disordered eating behaviours.  The authors therefore propose that the main goal of IPT is to reinstate positive interpersonal interactions so that self-esteem and positive affect can be developed without dependence on eating disorder behaviours.

Fidelity

IPT for eating disorders should be delivered by accredited IPT practitioners, who have typically already undertaken supervised case work in IPT for depression.  UCL competencies for IPT (Microsoft Word - IPT clinician guide.doc) highlight that practitioners delivering IPT should be able to draw on existing key knowledge of eating disorders. IPT should be delivered as per validated manuals, and content and structure are adhered to ensure consistency in delivery of intervention. Treatment adherence and practitioner competence should be monitored and evaluated using appropriate measures, e.g. via recording of treatment sessions and auditing of recorded sessions.  While there is not a specific adherence and quality scale for IPT for eating disorders, the therapy structure and majority of competencies are identical to IPT for depression, where the IPT-UK adherence and quality scale (https://iptinstitute.com/ipt-training-materials/ipt-quality-adherence-scale/) is a validated scale is used as a measure of adherence to treatment.

Modifiable Components

The initial IPT protocol for Bulimia Nervosa (IPT-BN) by Fairburn and colleagues (1991) was part of a comparison trial with CBT and Behaviour Therapy (2).  To enhance the difference between therapies, IPT techniques which were deemed too similar to CBT were stripped from the protocol including the symptom review, decision analysis and elements of psychoeducation (e.g. dietary education on regular eating and intake) which would be common in both IPT and standard eating disorder treatment. Arcelus and colleagues (2009) purposely reintroduced core IPT techniques into a subsequent version of the treatment manual and called it modified IPT for eating disorders (IPT-BNm) (3). This published manual reintroduces psychoeducation on eating disorder symptoms, dietary advice and encourages the use of food diaries throughout the intervention as part of the symptom review process.

IPT for BED is typically conducted in a group context, consisting of three phases over twenty weekly sessions. Wilfley and colleagues (2002) stress the importance of using the group context in this model as a “live social network” to address problems with initiating and sustaining relationship following an observation that a higher proportion of BED patients participating in these group identified with the sensitivities focal area than is commonly seen in IPT for depression (4).

Finally, Tanofsky-Kraff and colleagues (2010) developed IPT-WG which targets loss of control eating in adolescents (a subjective loss of control overeating, regardless of quantity, which is a more developmentally appropriate consideration for young people who rarely meet full criteria for BED) (5).  This is an adaptation of both the Young and colleagues (2006) adolescent prevention group for depression (IPT-AST) (6) and the Wilfley and colleagues (2002) group manual for Binge Eating Disorder (4). 

Implementation Support

Implementation support is provided by Interpersonal Psychotherapy UK (IPT UK), the UK based accredited body for therapists practicing Interpersonal Psychotherapy. They provide access to IPT training and supervision, IPT resources, accreditation documents, and CPD events. However, there is not a specific eating disorder training or accreditation, with the primary focus on IPT for depression.

Start-up Costs

Costs for IPT training include costs for the 5-day standard IPT training course (approx £1500, with additional costs (£2600) for supervision of clinicians who will work towards accredited IPT practitioner status.  There are additional yearly IPT UK membership fees. Please see the IPT-UK site for details of costs https://www.iptuk.net.  Some funded training places are available through NES (to IPT practitioner and supervisor status) for those clinicians working in CAMHS or adult mental health services nominated by their respective health boards.

Building Staff Competency

Qualifications Required

IPT is delivered by mental health practitioners including clinical psychologists, occupational therapists, psychiatrists, nurses, CBT therapists, counsellors and psychotherapists. Practitioners should hold current registration with a relevant professional body (e.g. HCPC, BACP, IACP, BABCP, GMC registered psychiatrist, BPS CAAP register), and have considerable post qualification experience in delivering supervised psychological therapy.  Clinicians delivering IPT for eating disorders are expected to draw on existing key knowledge on eating disorders.

Training Requirements

In the first instance, practitioners attend a 5-day standard IPT course which covers IPT theory, application, and clinical practice. Practitioners working towards accredited practitioner status will require accredited supervision. Under supervision, practitioners complete four cases, with recorded case sessions reviewed for IPT competencies. The first two cases need to be in depression, however further casework could be in an evidence-based model for other mental health problems e.g. eating disorders. Accreditation certificate is issued when the required criteria are met. Once individuals are an accredited practitioner, monthly supervision is required to maintain practice. This can be with practitioner peers in a group setting.

To be an IPT-UK accredited supervisor, practitioner need to complete NES training in supervision of psychological therapies and interventions (further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/) and specialist IPT supervision training components: specifically, two further IPT cases under accredited supervision, an IPT-UK accredited supervision course and an assessment of supervision of at least one case.

Supervision Requirements

Accreditation is conducted under regular supervision with an IPT-UK accredited supervisor. Supervision is provided weekly, with at least 12 of the 16 sessions attended per case. Supervisees are required to receive a minimum of four hours of supervision per case. Supervision is provided face to face or remotely, in individual or group formats.

Theory of Change

The IPT model can be explained by the following theories:

1. Attachment theory: This theory describes the ways in which relationships are developed, sustained and terminated, as well as how problems can develop within relationships. When attachment needs are met, people function optimally. However, when these attachment needs go unmet, people can become vulnerable to psychological distress and can develop symptoms of mental health disorders. IPT therefore aims to strengthen attachment and social bonds that are critical to interpersonal functioning.
2. Interpersonal theory: This theory proposes that humans have an intrinsic drive to form interpersonal relationships. When interpersonal relationships are disrupted, psychological distress and symptoms of mental health disorder can be experienced. By resolving current interpersonal problems, IPT can help patients improve interpersonal relationships and extend social networks, translating to enhanced interpersonal functioning, increased social support and symptom reduction.

IPT can also be explained by communication theory, social theory, as well as research on stress and illness, as these capture IPT’s targeted focus on the ‘here and now’ interpersonal problem areas.

Research Design & Number of Studies

Children and Young People Outcomes

The evidence for IPT in the treatment of eating disorders in children and young people is limited.  The evidence for IPT in the treatment of binge eating disorder is the most developed and is reviewed here.

A pilot RCT of family based IPT with overweight preadolescents at risk of loss of control eating involved 29 children, 8 to 13 years who had overweight/obesity and loss of control eating . Young people and their parents were randomized to 12‐week family based‐IPT (n = 15) or family-based health education (n = 14) and evaluated at post‐treatment, six‐months, and one‐year.

Tanofsky-Kraff and colleagues (2010) developed IPT-WG which targets loss of control eating in adolescents (a subjective loss of control overeating, regardless of quantity, which is a more developmentally appropriate consideration for young people who rarely meet full criteria for BED) (5). This is an adaptation of both the Young and colleagues (2006) adolescent prevention group for depression (IPT-AST) and the Wilfley and colleagues group manual for Binge Eating Disorder (6). Thirty-eight girls aged 12-17 years old were randomised of IPT-WG or a health education control group. A further RCT of this approach included 113 adolescent girls (12-17 years old) deemed at high risk of adult obesity and eating disorders due to a high BMI and reports of episodes of loss of control eating (8).

Adult Evidence and Outcomes

Some of the best available evidence for IPT in the treatment of eating disorders includes systematic reviews and randomised controlled studies.

A systematic review on IPT for eating disorders included 37 studies of which 10 where RCTs, 5 were follow up studies, 11 were secondary analyses of the same RCTs, 3 were case series, 4 were pilot studies and 4 were other experimental designs. The outcomes for the RCTs were summarised across AN, BN and BED (9).

A randomised study evaluated the effectiveness of IPT in adults with an eating disorder (including bulimia, binge eating disorder and other eating disorder) that required treatment (2). The study enrolled 130 participants, aged 18-65 years. IPT was delivered in twenty 50-min sessions, preceded by one 90-min preparatory session, and followed by a review session 20 weeks after treatment completion. The study was conducted in the UK.

The third paper was an RCT that evaluated the effectiveness of IPT in adults with binge eating disorder (10). The study included 205 adults, aged 18 years and over meeting the diagnostic criteria for binge eating disorder. IPT was delivered in 20 sessions, over 24-weeks. Participants were followed at 6-month intervals for 2 years after the end of treatment. The study was conducted in USA.

The fourth was a randomised trial that evaluated the effectiveness of group interpersonal psychotherapy in binge eating disorder (4). The study included 162 adults, aged 18-65 years, meeting the diagnostic criteria for binge eating disorder. IPT was delivered in 20 weekly 90-minute group sessions and 3 individual sessions. The study was conducted in USA.

Finally, there is an RCT that explored IPT for Anorexia Nervosa (11).  In a 20-week RCT, 56 females with Anorexia Nervosa were randomized to IPT, CBT or supportive clinical management.   

Values

Interpersonal psychotherapy (IPT) is a time-limited psychological intervention for the treatment of depression and other mental health disorders including eating disorders. IPT is present centred and focuses on addressing ‘here and now’ interpersonal problems areas for the purpose of helping patients achieve enhanced interpersonal functioning, increased social support and symptom remission. IPT can be explained by attachment theory, interpersonal theory and communication theory.

• Do the underpinning theories and the underlying mental health conditions addressed by the intervention align with the requirements of your organisation?

Priorities

IPT addresses interpersonal problem areas that are linked to distress and symptoms of mental health disorders, including eating disorders. IPT has been delivered in individual and group formats.

• What population will your service be offering IPT to?
• In what format will this intervention be delivered?

Existing Initiatives

• Does your service currently deliver interventions to treat mental health disorders including eating disorders and depression?
• Are existing initiatives practicable and effective? (2)
• Do existing initiatives fit current and anticipated requirements?

Workforce

IPT is delivered by mental health practitioners including clinical psychologists, occupational therapists, psychiatrists, nurses, CBT therapists, counsellors and psychotherapists, who hold current registration with a relevant professional body. To support the IPT delivery, practitioners attend a 5-day standard IPT course. Accredited supervision is required for practitioners working towards accredited practitioner status. Additional requirements apply for supervisor/ trainer certification. IPT is typically delivered to patients over 16 sessions.

• Does your service have qualified practitioners who are available and interested in learning and delivering IPT?
• Can your service support the time commitment required for practitioner training, supervision, and intervention delivery?

Technology Support

IPT can be delivered without access to technology but access to methods of recording sessions for review is helpful.

• Will IPT be delivered in-person or remotely?
• Does your service have the technology to support IPT remote delivery?
• Can your practitioners access technology to record sessions for review?

Administrative Support

IPT is typically delivered over 16 weekly sessions, each session lasting about 45-50 minutes. Face-to-face therapy sessions can be held in clinic, medical, and community settings. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.

• In what setting will IPT be delivered?
• Does your service have a venue to deliver IPT sessions?
• Can administrative supports needed to deliver this intervention be provided?

Financial Support

The 5-day standard IPT course costs £1475, with an additional £2600 for accredited supervision for practitioners working towards accredited practitioner status. Yearly IPT UK membership fees range from £25-£100.

• How many practitioners will your service train?
• What accredited status would practitioners in your service attain?
• Can your service financially support associated training and supervision costs?

Comparable Population

IPT has also been shown to be effective in the treatment of eating disorders in adults.

• Is this comparable to the population your service would like to serve?

Desired Outcome

IPT has been shown to effectively reduce eating disorder symptomatology, promote remission from binge eating disorder, and reduce interpersonal difficulties.

• Is delivering IPT for the treatment of mental health disorders including depression and eating disorders a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?