A Qualitative study of a modified v ersion of interpersonal psychotherapy for bulimic disorders:

1. A Qualitative study of a modified version of interpersonal psychotherapy for bulimic disorders: Michelle Haslam Dr Jon Arcelus, Professor Caroline Meyer

2. 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.

3. 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.

4. 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

5. 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.

6. 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.

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

8. 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.

9. 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

10. 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.

11. 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.’

12. 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’

13. ‘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.’

14. 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.’

15. 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.

16. 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

17. 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

18. 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!’

19. 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.’

20. 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

21. 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)

22. 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)

23. 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)

24. 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)

25. 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)

26. 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)

27. 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)

28. 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)

29. Why therapy helped Form Structure of therapy Being able to talk Therapeutic alliance Less ‘pressure’ to change Taking on the sick role Content of the therapy Focus on relationships Focus on food Psychoeducation Techniques Role play Food diaries Challenging ED thoughts/behaviours

30. 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)

31. 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)

32. 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)

33. 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

34. Thank you for listening. Any questions?