An eating disorder-specific model of interpersonal psychotherapy (IPT-ED): Causal pathways and treatment implications

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Abstract

Several studies support the efficacy of interpersonal psychotherapy (IPT) in the treatment of eating disorders. Treatment outcomes are likely to be augmented through a greater understanding, and hence treatment targeting, of the mechanisms whereby IPT induces therapeutic gains. To this end, the present paper seeks to develop a theoretical model of IPT in the context of eating disorders (IPT-ED). After providing a brief description of IPT, the IPT-ED model is presented and research supporting its theorized mechanisms is summarized. This model proposes that negative social evaluation plays a pivotal role as both a cause (via its detrimental impact on self evaluation and associated affect) and consequence of eating disorder symptoms. In the final section, key eating disorder constructs (namely, the developmental period of adolescence, clinical perfectionism, cognitive dysfunction, and affect regulation) are re-interpreted from the standpoint of negative social evaluation thereby further explicating IPT's efficacy as an intervention for individuals with an eating disorder.

Introduction

Among psychiatric conditions, eating disorders are unique in that their core features—the control of body shape, weight, and eating—have immense social currency in cultural settings in which thinness and/or dietary restraint are highly valued. These varied settings include medieval female saints whose religious tradition venerated suffering and denigrated the flesh (Bell, 1985), Chinese Daoist practices that emphasize fasting as a means of attaining spiritual perfection (Eskildsen, 1998), or the “cult of thinness” of contemporary Western culture (Hesse-Biber, Leavy, Quinn, & Zoino, 2006, p. 208). The social status to be gained from bodily and dietary control can only be enhanced in societies where the majority of individuals struggle with problems of overweight or obesity (World Health Organization, 1998). That aspects of eating disorder symptomatology are socially prescribed, suggests a central role for interpersonal factors in the development and maintenance of these conditions.

Consistent with an interpersonal formulation of eating disorders, there is abundant evidence highlighting the existence of interpersonal dysfunction in the lives of individuals with an eating disorder (for a review, see Wilfley, Stein, & Welch, 2003). Moreover, there is support for the efficacy of interpersonal psychotherapy (IPT), an approach that targets interpersonal problems as a means of resolving psychological symptoms (Klerman et al., 1984, Weissman et al., 2000), in the treatment of eating disorders (e.g., Agras et al., 2000, Wilfley et al., 1993, Wilfley et al., 2002).

Yet in stark contrast to cognitive behavior therapy (CBT), in which eating disorder-specific adaptations were originally formulated in the 1980s (e.g., Fairburn, 1985), there is no empirically supported theoretical model of IPT for eating disorders. The insufficient theoretical foundation of IPT is not unique to eating disorders and is partly the legacy of IPT having evolved in the context of treatment outcome evaluation such that questions as to why it is effective have lagged behind questions as to whether it is effective (Stuart & Robertson, 2003).

Nevertheless, both general (Stuart & Robertson, 2003) and disorder-specific models of IPT have been proposed, such as IPT for depression (Frank & Spanier, 1995), dysthymia (Markowitz, 2003), and borderline personality disorder (Markowitz, Skodol, & Bleiberg, 2006). Attachment theory (Bowlby, 1977) has been described as the theoretical foundation of IPT in that psychological problems are hypothesized to develop when an individual's needs for attachment (i.e., strong affectional bonds with preferred others) are not being met (Stuart & Robertson, 2003). These bonds “provide opportunities for intimacy, nurturance, validation of self worth, and a sense of connectedness with others” (Frank & Spanier, 1995, p. 353) and their disruption results in various forms of emotional distress such as anxiety, depression, and anger. However, these attachment-based approaches were not designed to account for the mechanisms by which attachment disturbances elicit eating disorder symptoms as opposed to other forms of psychopathology.

To initiate the process of theory-building in IPT for individuals with an eating disorder, the present paper proposes a theoretical model that seeks to explain IPT's efficacy and to guide its future implementations in this population. After providing a brief overview of IPT, the paper is divided into two sections. The first section presents our theoretical model of IPT for eating disorders (IPT-ED), beginning with an overview of the model followed by a review of the research supporting the theorized mechanisms by which specific interpersonal problems maintain, and are in turn maintained by, eating disorder symptoms. Emphasizing the validating aspects of attachment bonds, it will be argued that negative social evaluation plays a central role in triggering disturbances of the self and hence eating disorder symptoms. Given the primacy of negative social evaluation in our IPT-ED model, the second section provides a re-examination of several key eating disorder relevant constructs (including the developmental stage of adolescence as a risk period for the onset of eating disorders, clinical perfectionism, dysfunctional cognitive processes, and affect regulation strategies) from the perspective of negative social evaluation.

Section snippets

Overview of IPT

IPT originated as a standardized form of interpersonally-oriented psychotherapy for use in treatment outcome research on depression (Birchall, 1999, Swartz, 1999, Tantleff-Dunn et al., 2004, Weissman, 2007). As with CBT, IPT is typically implemented as a time-limited treatment, consisting of 12 to 20 sessions spanning four to six months (Birchall, 1999, Wilson, 2005). IPT is well tolerated by patients and is easily learned by competent therapists (Birchall, 1999, Crafti, 2002, Tantleff-Dunn et

Overview of the IPT-ED model

Our proposed model of IPT for eating disorders (IPT-ED) draws upon longstanding conceptualizations of eating disorders in ascribing a pivotal role to disturbances of the self in the development and maintenance of eating disorder symptoms but adds to these approaches by emphasizing links between disturbances of the self and the individual's experiences and perceptions of his/her social world. Chief among the disturbances of the self that are relevant for eating disorders are negative self

The reconceptualization of eating disorder related constructs in social evaluative terms

In giving primacy to negative social evaluation in the maintenance of eating disorder symptoms, a key implication of the IPT-ED model is the need to broaden previous understandings of various eating disorder relevant constructs so as to acknowledge the role of social evaluative concerns. Among these are the mechanisms by which the adolescent period, clinical perfectionism, cognitive dysfunction, and affect regulation strategies are involved in the maintenance of eating disorders.

Concluding comments

Due to the relative paucity of research (particularly utilizing experimental designs) investigating interpersonal factors and eating disorders, the proposed IPT-ED model is necessarily in nascent form. Nevertheless, it is hoped that the model will stimulate further research and hence ongoing development and refinement of theories and treatments regarding the interpersonal aspects of eating disorders.

Since our IPT-ED model highlights the centrality of actual or perceived negative social

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