The four- or five-session termination phase is a time for reflection on what has been achieved during treatment, and what is to be accomplished in the future. Prior to the start of termination, the clinician should clearly address it and establish open communication with the patient regarding his or her feelings about ending treatment. Some patients may experience a sense of grief or anxiety, while others may seem unaffected by termination. The clinician’s role is to attend to the patient’s reactions and to encourage healthy emotional expression.
IPT does not assume that the patient’s work toward changing his or her interpersonal patterns ends with treatment. Thus, in addition to reflecting on accomplishments, clinicians and patients should collaboratively develop additional goals for patients to work on following termination. In addition, relapse prevention should be addressed during the termination phase. The therapist should help the patient identify signs of relapse (e.g., negative mood, chaotic eating, dietary restriction) and develop an action plan. Again, clinicians should explicitly connect interpersonal stress and eating disorder symptoms when discussing relapse prevention. The collaborative nature of this phase is crucial for instilling a patient’s sense of efficacy and security. Patients must feel that they have the tools necessary for maintaining their recovery. However, clinicians should be cautious to identify warning signs that may indicate a need for the patient to again seek professional help.
CASE EXAMPLE Initial Phase
Muriel was in her early thirties and the married mother of a school-age child with cerebral palsy when she presented for treatment. She stated that she was experiencing problems with her weight and eating, which she felt had increased over the past four years with her son’s entry into the special school system. Muriel reported feeling simultaneously bored and overwhelmed by the number of household tasks that she felt she needed to address while her son was in school, and by the number of appointments related to care for her son’s medical condition.
Muriel noted that she first began to have concerns about her shape and weight when her father started making critical comments to her about the weight she had gained during her freshman year in college. While in college, she began to restrict her caloric intake and exercise specifically in an attempt to lose weight. Although she had occasional periods when she overate and felt badly afterwards, her first episode of binge eating occurred when she was on bedrest during her pregnancy. She stated that she was worried about weight gain, lonely, bored, and anxious about the health of her fetus. In addition, she resented that her family did not attempt to take care of her during this difficult time in her life despite the fact that she was “always there for them.” However, she never expressed these feelings to her family since “they had so much to deal with themselves.”
Muriel’s responses on the Eating Disorder Examination, a structured interview designed to assess eating disorder pathology based upon DSM-IV criteria (Fairburn et al., 1993), were consistent with a diagnosis of BED. During assessment, Muriel reported binge eating on average once or twice a day most days of the week. These episodes of binge eating were followed by intense feelings of self-loathing. She was most likely to binge eat at night after her son was in bed, during the day when he was napping or at school, or after a stressful visit with her mother.
Muriel also endorsed significant symptoms of depression on the Beck Depression Inventory (BDI = 30). Muriel reported a positive family history for depression and had been diagnosed and successfully treated for postpartum depression with medication and brief counseling following her son’s birth. Though hesitant to resume taking medication, she was open to pursuing psychotherapy for treatment of both her eating and mood problems.
In the first session, Muriel was informed of the “good news/bad news” results of the clinical assessment. The “bad” news was that she did indeed meet diagnostic criteria for BED and for recurrent major depression, and had been trying to deal with these extremely difficult problems by herself for a very long time. The good news was that IPT was a treatment available to her that had demonstrated efficacy in improving symptoms of both her eating disorder and depressed mood. Although initially resistant to receiving this diagnosis (and the assignment of the “sick role”), Muriel was responsive to the rationale for treating these problems within an interpersonal framework. Furthermore, she readily engaged in the process of linking her eating and mood symptoms to relationships and significant life events throughout the course of conducting the interpersonal inventory.