Transcript Slide 1

A Qualitative study of a modified
version of interpersonal
psychotherapy for bulimic disorders:
Michelle Haslam
Dr 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
Method
Participants
14 female outpatients with a bulimic disorders
from LEDS aged between 19 and 40.
Procedure
Following treatment completion participants were invited
by their therapist to meet with the researcher who
explained the research further. Semi-structured
interviews were conducted at the service, lasting around
45 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 analysis
Interviews were transcribed verbatim and analysed using
thematic 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
Behaviours
There were 14 female participants aged between 18 and
45, 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, none
were taking laxatives.
Length of illness ranged from 6 months to 25 years.
Results: interpersonal problems before
starting therapy
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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 starting
therapy
Social avoidance
Avoiding people and situations where interactions with
people 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 network
Eating disorder results in lost friendships.
Not utilising social support
Patients described having friends and family around
them 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 intimacy
Relationships with significant others lack closeness and
communication.
‘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 and
eating
‘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.’
Summary
Patients report experiencing a variety of
interpersonal problems, characterised by a lack
of social interaction and closeness in
relationships .
Next: explore patients’ symptoms and
interpersonal problems after IPT-BNm.
What therapy has helped with
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
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Social reintegration
Learning to be more open in relationships
Increase in assertiveness
A reduction in mood swings
Relationship dissolution
Social reintegration
An improvement in both new relationships and
old
‘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 contact
with.... I have arranged meetings with
several people I went to school with and
haven'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 and
new 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 four
subthemes, which explain exactly how the
patient feels more able to be genuine in
relationships after therapy:
a) A more healthy attitude towards emotional
expression
b) Asking for help
c) Reduction in perfectionism
d) 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 is
linked to asking for help is a reduction in
perfectionism.
‘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 and
open.
‘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 assertiveness
Patients 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 aggressive
towards other people at the end of therapy as they
were more in control of their mood as their diet
improved.
‘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 dissolution
Sometimes it was considered that relationships were too
unhealthy and therapy helped patients to take a step
back from these relationships, and find suitable
alternatives.
‘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 therapy
Focus on relationships
Focus on food
Psychoeducation
Techniques
Role play
Food diaries
Challenging ED
thoughts/behaviours
Form
Structure of therapy
Being able to talk
Therapeutic alliance
Less ‘pressure’ to change
Taking on the sick role
What therapy hasn’t helped with
Eating disorder as a lifelong problem
‘I think it has helped but I think it’s the beginning of me having to do a lot
more 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’t
think of a straightforward way to solve that, and stuff like that that we haven’t
really covered.’ (12)
Not all relationships targeted
‘Yeah I mean I’ve got a very difficult relationship with my mum, I’ve got an
older brother who I don’t speak to at all, I mean yeah relationships were
addressed, but I think there was more to address if you see what I mean. There
was more to it than was discussed and we just didn’t have the time to discuss
it.’ (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?