A Qualitative study of a modified version of interpersonal

psychotherapy for bulimic disorders:

Michelle HaslamDr Jon Arcelus, Professor Caroline

Meyer

Introduction

• Interpersonal Psychotherapy (IPT) assumes that psychiatric syndromes occur in a social and interpersonal context.

• The rationale of IPT for BN suggests that ED attitudes and behaviours are responses to interpersonal disturbances.

• IPT aims to reduce bulimic attitudes and behaviours by improving the individuals ability to utilise their social support networks and manage these interpersonal deficits.

• The modified version of IPT-BN reintroduces a focus on food and techniques such as psychoeducation

• Currently there are no qualitative studies exploring the interpersonal experiences of patients with BN or their treatment.

Aims

• To explore patients experiences of interpersonal problems before therapy began

• To explore their perceptions of IPT-BNm, how it helped them and why, and how it did not help them and why

MethodParticipants14 female outpatients with a bulimic disordersfrom LEDS aged between 19 and 40.

ProcedureFollowing treatment completion participants were

invitedby their therapist to meet with the researcher whoexplained the research further. Semi-structuredinterviews were conducted at the service, lasting around45 minutes.

Key questions:• How do patients perceive their interpersonal

relationships and eating disorder symptoms before and after treatment?

• How did patients perceive the treatment and which aspects were experienced as positive and negative?

• What factors do they consider to be associated with positive and negative outcome?

Data analysisInterviews were transcribed verbatim and analysed usingthematic analysis for emergent themes.

Preliminary results

• How do patients perceive their interpersonal relationships and eating disorder symptoms before treatment began?

Results: eating disorder attitudes and behaviours before therapy

BehavioursThere were 14 female participants aged between 18 and45, with a mean age of 31.64 years (SD=7.29).Participants were diagnosed with either bulimia nervosa(n=10) or atypical bulimia nervosa(n=4)

All bingeing daily, 2 were exercising excessively, nonewere taking laxatives.

Length of illness ranged from 6 months to 25 years.

Results: interpersonal problems before starting therapy

• Social avoidance• Depleted social network. Not utilising support• Lack of intimacy• Negative attitude towards emotional expression• ‘False’ interactions• Fear of negative evaluation• Lack of assertiveness• Problems identifying links between life events

and eating

Results: interpersonal problems before startingtherapy

Social avoidanceAvoiding people and situations where interactions withpeople are necessary.

‘I guess I had set my life up so that I didn't have to see people and when I did I didn't really have to talk to them. So, for example, at work I would try to go into the office as little as possible and work at home instead, and when I did have to go in I would just get on with my work and avoid talking to anyone I didn't have to.’

Particularly common regarding situations involving food e.g. meals out.

Depleted social networkEating disorder results in lost friendships.

Not utilising social supportPatients described having friends and family aroundthem for support, but choosing not to utilise them.

‘I have got supportive friends and I know that if I ever did have a problem I could give them a call and have a chat. But I just don’t.’

Lack of intimacyRelationships with significant others lack closeness andcommunication.

‘My natural instinct is to withdraw and to cut myself off ...’

This was particularly the case for talking about ED.

This could be partly due to.....

Negative attitude towards emotional expression‘Only about three of them know I have an eating problem,

because I don’t want people to feel sorry for me or approach me in different ways’

‘False’ interactions‘I guess I also felt that when I did interact with people I

was putting on an act of some kind, and so these weren't 'real' interactions anyway..... I was pretending everything was fine when it wasnt’

Being the life and soul of the party.

Fear of negative evaluation‘‘there’s that hideous one’. That’s how I perceive what

other people think.’

Lack of assertiveness‘I’m not a confrontational person so I find it difficult to

stand up for myself. I would just take the blame, even though I know I wasn’t in the wrong.’

Problems identifying links between life events andeating‘I think before it was getting to nine at nine and I’d think

I’m really hungry, I’ll have a sandwich, and then that would become two sandwiches then three sandwiches. Whereas now I think, well I can’t be hungry, I’ve eaten really well during the day, what is it that’s making me feel hungry now, because it’s not hunger it’s something else.’

SummaryPatients report experiencing a variety ofinterpersonal problems, characterised by a lackof social interaction and closeness inrelationships .

Next: explore patients’ symptoms andinterpersonal problems after IPT-BNm.

Eating

• A reduction in bulimic behaviours

• Meal structure

• Identifying triggers and coping strategies

• Food as a friend

• A better understanding of nutrition

What therapy has helped with

Interpersonal functioning• Social reintegration• Learning to be more open in relationships• Increase in assertiveness• A reduction in mood swings• Relationship dissolution

What therapy has helped with

Social reintegrationAn improvement in both new relationships andold

‘Now, as a direct consequence of the IPT, I actively seek out contact with other people and in the course of therapy made several good friends at work who I keep in contactwith.... I have arranged meetings withseveral people I went to school with andhaven't seen for about 15 years!’

Being more open in relationships

Patients felt more able to be honest and‘real’ in social situations within existing andnew relationships.

‘…as part of the therapy my therapist tried to encourage me to be myself and not to feel like I had to put on an act when I was with other people, which I was able to in conjunction with the other techniques and the medication.’

This theme has been broken down into foursubthemes, which explain exactly how thepatient feels more able to be genuine inrelationships after therapy:

a) A more healthy attitude towards emotional expression

b) Asking for helpc) Reduction in perfectionismd) Reduction in fear of negative evaluation

a) A more healthy attitude towards emotional expression

Patients report feeling better able to express their emotions to others.

‘before if things were upsetting or worrying

me I would have tried to keep them to myself, whereas now I think well they might be able to help me or talking about it with them might help me.’ (1)

b) Asking for help

Patients describe feeling more able to ask others for help when it was needed.

‘I’ve just realised you can’t do things on your own, and I guess I don’t feel so bad about asking for help.’ (4)

‘I did actually realise how poor my support

network was, when I thought about it. I’m making very very small steps to rectify that, and calling on a few extra people to help out now and then.’ (9)

c) More self compassion

Another experience that patients report that islinked to asking for help is a reduction inperfectionism.

‘I think I realised that....it’s ok not to get things right first time.’ (4)

‘I just address things a little bit more differently

and realise that I have limitations like everybody else.’ (9)

d) Reduction in fear of negative evaluation

This allows people to be more genuine andopen.

‘Oh, I’m out all the time now. Never in. It’s not that I don’t care what people think but I think, well this is me, so like me for me.’ (3)

Increase in assertivenessPatients feel better able to set boundaries with others. ‘…people just think they can ring me up and ask me to

do whatever, and that I don’t do anything I just sit on my bum all day. They just think oh Kerry* will do it. So I did learn how to say no to people in a nice way and managing it so I don’t get stressed and it leads to bingeing.’(11)

They were therefore better able to deal with relationship problems:

‘…if I do get angry or upset about something, I

can take some time and take some space, but to say, ‘actually when that happened it upset me’, and that’s not being right there in the moment that its happened, but maybe going back later, to kind of deal with it then in a more constructive way’. (5)

A reduction in irritability

Patients felt they were less likely to be aggressivetowards other people at the end of therapy as theywere more in control of their mood as their dietimproved. ‘Because of the chaotic eating, it might fulfil the

criteria of trying to reduce my intake and stop me getting fat but what it does definitely do is make you a lot more volatile mood wise. Because I find that if I let myself get hungry and I feel faint, I’m very irritable. So I’ve reduced the instances of that.’ (7)

Relationship dissolutionSometimes it was considered that relationships were toounhealthy and therapy helped patients to take a stepback from these relationships, and find suitablealternatives. ‘because I’d ring them up and piss myself off, and think

what did you do that for, when they’re telling you what a good night they’ve had and that they’ve got a new dress and that they’re a size eight. While you’re sat at home ramming takeaways down your throat. It’s been a change of lifestyle but a good change of lifestyle. It’s nice. Before I was running behind them and trying to be like them, but they weren’t there for me.’ (14)

Why therapy helped

Content of the therapyFocus on relationships

Focus on foodPsychoeducation

FormStructure of therapy

Being able to talkTherapeutic alliance

Less ‘pressure’ to changeTaking on the sick role

TechniquesRole play

Food diariesChallenging ED

thoughts/behaviours

What therapy hasn’t helped withEating disorder as a lifelong problem ‘I think it has helped but I think it’s the beginning of me having to do a lotmore work. Like, it’s not magically cured me.’ (12) Body image ‘..stuff like body image I have no idea how you would go about it, I can’tthink of a straightforward way to solve that, and stuff like that that we haven’treally covered.’ (12) Not all relationships targeted ‘Yeah I mean I’ve got a very difficult relationship with my mum, I’ve got anolder brother who I don’t speak to at all, I mean yeah relationships wereaddressed, but I think there was more to address if you see what I mean. Therewas more to it than was discussed and we just didn’t have the time to discussit.’ (6)

Barriers to treatment

Lack of motivation to change ‘ ..this is going to sound awful but I don’t have a big desire to stop

bingeing. Because eating is something you do everyday regardless, eating and drinking, it’s a normal thing.’ (10)

‘I wonder whether underneath, there’s a part of me that doesn’t want to do it. I quite like living this. But I’m unhappy with it, so that doesn’t make sense.’ (2)

Passivity ‘I mean if anybody could just give me something to get rid of it, I’ll be

joyful.’ (2) ‘Oh, I’d like somebody just to have come along and put a vacuum

cleaner inside my head and get rid of it all, that would have been lovely.’ (9)

Longevity of the eating disorder Two patients expressed that they felt therapy was not designed for those who had

been suffering from an eating disorder for many years. ‘ …three quarters of an hour I just don’t think is long enough. I mean I’ve been

suffering for 20 years so I think you know, 16 weeks, which may seem a long time, but obviously when you’ve had it for 20 years it’s a very complicated illness’(6)

Problems in short term memory One patient who was prescribed antidepressants reported that she found her

memory affected the efficacy of the therapy. ‘Because of the medication I find my short term memory is affected quite badly.

So sometimes I can go away and think I’ve had no idea what we’ve talked about today, or what we’ve achieved or what we’ve worked on.’ (8)

Summary

• On the whole, patients report that IPT-BN(m) is beneficial

• Therapy helps them to improve both their eating and their relationships with others

• However IPT-BN(m) is not a ‘cure’, and for most there are still residual symptoms at the end of therapy

• IPT-BN(m) may work better for people who have not had bulimia for so long, and who are high in motivation to change

Thank you for listening. Any questions?