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).