Interpersonal Psychotherapy for Bulimia Nervosa

Christopher G. Fairburn, D. M., FRCPsych.

Oxford University Department of Psychiatry
Warneford Hospital Oxford, United Kingdom

Reprinted from:
Fairburn, C. G., (1994). Interpersonal psychotherapy for bulimia nervosa. The Clinical Psychologist, 47(4), 21-22.


I. Description of Treatment

Interpersonal psychotherapy (IPT) is a short-term focal psychotherapy in which the goal is to help patients identify and modify current interpersonal problems. It was developed in the 1940's as a treatment for clinical depression (see accompanying article by Cornes and Frank). More recently, it has been applied to other problems including recurrent depression, substance abuse, marital problems and eating disorders. In this paper its application to bulimia nervosa is considered.

IPT for bulimia nervosa resembles IPT for depression in its style and structure. Thus it is a non-interpretive, non-directive form of individual psychotherapy involving 15 to 20 50-minute sessions over four to five months. The treatment has three stages. In the first, the goal is to engage the patient in treatment, identify current interpersonal problems and establish a treatment contract. This usually takes three or four sessions. Three sources of information are used to identify the problems: first, an evaluation of the interpersonal context in which the eating problem developed and, more importantly, has been maintained; second, an assessment of the quality of the patient's current interpersonal functioning; and third, as examination of the interpersonal context of individual bulimic episodes. This stage ends with the therapist and patient deciding which of the identified problems will be the focus of the remainder of treatment.

As originally developed, the second and third stages of the treatment are identical to IPT for depression except that the patient is put under more pressure to change. The eating disorder is not directly addressed: if it is mentioned by the patient, the therapist promptly shifts the focus on to its interpersonal context.

IPT for bulimia nervosa appears to be as effective as the leading treatment for the disorder (see below), a specific adaptation of cognitive behavior therapy (CBT) (Fairburn, 1981; Fairburn, Marcus, & Wilson, 1993). Since neither treatment is a panacea, there is a need to explore ways to enhancing their efficacy. A logical approach would be to combine the two so that both the eating disorder and accompanying interpersonal problems were directly addressed. Unfortunately this is not possible since the styles of the two therapies are so different as to make them incompatible. For this reason the author's group now combines IPT with the use of a self-help program based directly on the cognitive behavioral approach (Fairburn, 1995). The patient follows the self-help program with the encouragement of the therapist whilst at the same time receiving IPT. This combination seems to work well.

Whether IPT for bulimia nervosa can be used in a group format is uncertain. A group version has been used by Wilfley and colleagues to treat obese patients who binge eat (Wilfley, Agras, Telch, Rossiter, Schneider, & Cole, 1993).


II. Summary of Studies Supporting Treatment Efficacy

Two studies, both conducted by the author's group at Oxford, provide the empirical support for using IPT to treat patients with bulimia nervosa. In the first (Fairburn, Kirk, O'Connor, & Cooper, 1986), cognitive behavior therapy was compared with a form of short-term focal interpersonal therapy. Patients in both treatment conditions improved substantially with the changes being maintained over a twelve-month treatment-free follow-up period.

In the second study, we replaced the original interpersonal treatment with IPT since it was similar in style and focus while having the advantage of being better established and there being a detailed treatment manual. The results indicated that CBT and IPT were equally effective (Fairburn, Jones, Peveler, Carr, Solomon, & O'Connor, 1991; Fairburn, Jones, Peveler, Hope, & O'Connor, 1993). CBT was more rapid in its action with almost all the changes occurring during treatment itself, whereas with IPT the changes were more gradual but they continued during follow-up.

Taken together, the findings of these two studies suggest that short-term focal interpersonal therapy provides a new method for treating bulimia nervosa. It has yet to be established whether certain types of patient respond preferentially to this treatment as against CBT.


III. Clinical References

IPT for depression is described in full in Interpersonal Psychotherapy for Depression (Klerman, Weissman, Rounsaville, & Chevron, 1984) and its adaptation for bulimia nervosa is covered in a chapter (Fairburn, 1992) in the complementary volume New Adaptations of Interpersonal Psychotherapy.


References

Fairburn, C. G. (1981). A cognitive behavioural approach to the management of bulimia. Psychol Med, 11, 707-711.

Fairburn, C. G. (1992). Interpersonal psychotherapy for bulimia nervosa. In G. L. Klerman & M. W. Weissman (Eds.), New applications of interpersonal psychotherapy (pp.353-378). Washington, D. C.: American Psychiatric Press.

Fairburn, C. G. (1995). Overcoming binge eating. New York: Guilford Press.

Fairburn, C. G., Jones, R., Peveler, R. C., Carr, S. J., Solomon, R. A., O'Connor, M. E., Burton, J., & Hope, R. A. (1991). Three psychological treatments for bulimia nervosa: A comparative trial. Arch Gen Psychiatry, 48, 463-469.

Fairburn, C. G., Jones, R., Peveler, R. C., Hope, R. A., & O'Connor, M. (1993). Psychotherapy and bulimia nervosa: The longer-term effects of interpersonal psychotherapy, behaviour therapy and cognitive behaviour therapy. Arch Gen Psychiatry, 50, 419-428.

Fairburn, C. G., Kirk, J., O'Connor, M., & Cooper, P. J. (1986). A comparison of two psychological treatments for bulimia nervosa. Behav Res Ther, 24, 629-643.

Fairburn, C. G., Marcus, M.D., & Wilson, G. T. (1993). Cognitive-behavioral therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment and treatment (pp. 361-404). New York: Guilford Press.

Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984). Interpersonal psychotherapy of depression. New York: Basic Books.

Wilfley, D. E., Agras, W. S., Telch, C. F., Rossiter, E. M., Schneider, J. A., Cole, A. G., Sifford, L., & Raeburn, S. D. (1993). Group cognitive-behavioral therapy and group interpersonal psychotherapy for the nonpurging bulimic individual: A controlled comparison. Journal of Consulting and Clinical Psychology, 61, 296-305.


IV. Resources for Training

Means of obtaining training in IPT are described in a previous article in TCP by Cornes and Frank (see The Clinical Psychologist, 1994, 47, 9-10). In addition, the author regularly holds workshops on IPT for bulimia nervosa.


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