Bulimia Nervosa

WHAT IS BULIMIA NERVOSA?

Bulimia nervosa, commonly called bulimia, is an eating disorder that involves binge eating followed by some type of behavior to prevent weight gain.¹ Usually, this means that people purge themselves of food they’ve just eaten in order to remove the food before it can be digested.

Binge eating is an activity that takes place in the span of a few hours and usually involves consumption of a large quantity of high-calorie foods. For example, this could mean that a person eats multiple bags of candy and chips at home, or it could mean going to a number of different fast-food restaurants in a short period of time to eat multiple meals. Most often, this type of behavior is done in secret and alone.¹ Many people binge because they feel stressed, anxious, depressed, or extremely hungry.¹ During bingeing, some people feel that they’re out of control and can’t stop eating, while others report feeling like they’re outside of their bodies.¹

After eating such large quantities of high-calorie foods, people with bulimia feel guilty about what they’ve done and become fearful of gaining weight. So immediately after eating, 80 to 90 percent of them force themselves to vomit to prevent the food from being digested.¹ However, purging can also be accomplished through the abuse of laxatives, diuretics, enemas, or syrup of ipecac. Other people with bulimia offset their binge eating by engaging in excessive exercise or by fasting for multiple days.

People suffering with bulimia frequently battle an intense fear of gaining weight and becoming fat. They spend a great deal of time analyzing their looks in the mirror, and no matter how much weight they lose, they never think it’s enough. People with bulimia never think they look good enough, despite the excessive amount of time they spend focusing on the way they look and limiting the amount of food they digest. The inability to see the danger of their situation is part of the disorder.

Similarly, some people with anorexia also engage in bingeing and purging behaviors. However, a person struggling with anorexia weighs 85 percent or less of what is considered normal for someone of the same age, sex, and height, while most people with bulimia weigh approximately their normal expected weight.¹ A person who regularly binges without purging, exercising, or fasting might be diagnosed as suffering from binge-eating disorder.¹

ARE THERE OTHER PROBLEMS RELATED TO BULIMIA NERVOSA?

Although the risk of dying from bulimia is much less severe than the risk of dying from anorexia,^{2, 3} there are still many serious health problems that will persist for as long as the bingeing and purging continue. These problems include sore throat, erosion of tooth enamel, swelling of the salivary glands, stomach acid reflux,⁴ upset stomach,⁵ severe constipation,⁶ and severe fluid and electrolyte imbalances that can lead to heart arrhythmias.^{7, 8} Additionally, the abuse of ipecac can lead to heart damage and general muscle weakness.⁹ The good news is that most of these problems are reversible, especially if bulimia is treated early in its course.⁴

In addition, many people battling bulimia also struggle with depression,^{10, 11} obsessive-compulsive disorder,¹² alcohol and drug addiction (especially to amphetamines, marijuana, and tranquilizers),¹³ and borderline personality disorder.^{14, 15}

WHO IS AFFECTED BY BULIMIA NERVOSA?

Bulimia usually begins during adolescence and has the greatest likelihood of starting around age eighteen.¹⁶ It’s estimated that approximately 3 percent of all women will develop bulimia at some point in their lives.^{1, 17} However, for college-age women the risk is slightly higher, at 5 percent.¹⁸ For men, the odds appear to be much less. Men are diagnosed with bulimia ten to twenty times less often than women.¹⁹ However, it’s believed that these numbers might be low, either due to the assumption that eating disorders affect only women and therefore go undiagnosed in men, or due to the fact that men are ashamed of reporting bulimia.^20-23 Some research does indicate, however, that men who identify themselves as gay or bisexual are often at a greater risk for developing bulimia than are heterosexual men.²⁴

WHAT CAUSES BULIMIA NERVOSA?

The exact causes of bulimia are still unknown.⁴ Like many other mental health issues, it’s probably caused by a combination of hereditary²⁵ and environmental factors.²⁶ In a study of developmental risk factors, women with bulimia were more likely to report past experiences of obesity, sexual and physical abuse, depression, substance abuse, low self-esteem, a sense of perfectionism, disturbed family relationships, and obese parents.²⁷ These findings seem to indicate that the development of bulimia is the result of being exposed to general risk factors for both mental health problems and extreme dieting. However, the results of this one study are by no means definitive.

Other theories suggest that the Western ideal of thinness²⁸ and the media’s depiction of women²⁹ are at least partly responsible. Still another theory suggests that women of color may develop eating disorders when their cultural view of their own body image comes into conflict with that of the majority culture.³⁰

WHAT TREATMENTS ARE EFFECTIVE FOR BULIMIA NERVOSA?

According to a 2003 report published in the New England Journal of Medicine,4 the most effective form of treatment for bulimia is cognitive behavioral therapy, which in some cases is even more effective than the use of medications alone.³¹ In various studies, cognitive behavioral therapy has resulted in 45 to 49 percent rates of full recovery,^{31, 32} and a 70 to 94 percent success rate in reducing bingeing and purging behaviors.³³ Cognitive behavioral therapy for bulimia has been effective in both group and individual therapy settings,^{34, 35} and the effects of the treatment appear to be long lasting.³⁶

Interpersonal therapy³² and self-psychology³⁷ (a form of psychodynamic treatment) have also shown some success in treating bulimia. Acceptance and commitment therapy, a form of behavioral therapy, was reported to be successful in treating a single case study of anorexia,³⁸ and therefore might also be effective in treating bulimia.

Studies of antidepressants, especially fluoxetine (Prozac), have demonstrated some short-term success using the medication alone and in combination with cognitive behavioral therapy.³¹ However, the long-term success of these drugs is still unknown.³⁹

The advice of a certified dietician can also be beneficial. In a 2004 study published in the International Journal of Eating Disorders, researchers added protein to the diets of women with bulimia and found that these women exhibited less binge eating, reported less hunger and greater fullness, and consumed less food between meals over the two-week course of the study.⁴⁰

COGNITIVE BEHAVIORAL THERAPY FOR BULIMIA NERVOSA

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.

The CBT treatment for bulimia is often composed of nine steps:^{41, 42}

Conduct an assessment and provide education
Address health and eating issues
Develop coping strategies
Challenge and correct self-defeating thoughts
Develop a healthier body image
Increase self-esteem
Develop emotion regulation skills
Treat related problems
Prevent relapse

1. Conduct an Assessment and Provide Education

The first step of the CBT treatment for bulimia is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with bulimia and not some other similar problem, such as anorexia or binge-eating disorder. Once people have been diagnosed with bulimia, it’s important that they and their family members understand the basic nature and causes of the disorder (as highlighted above). Family support is very important, since family issues often contribute to the development and maintenance of bulimia. It’s also important for everyone involved to understand that CBT is an interactive treatment that requires the person and his or her loved ones to do work outside of the therapy session. Early in treatment, the person might be asked to keep track of bingeing and purging activities using activity logs, or be asked to use worksheets to balance the costs and benefits of changing behaviors. (Click here for more information about assessing bulimia and educating the patient and family.)

2. Address Health and Eating Issues

Early in treatment, it’s often helpful and necessary to have the assistance of a medical and/or nutritional specialist. It’s crucial that the person with bulimia understand the dangers of bingeing and purging and the negative side effects of dieting. It’s also very important that the person learn about the necessity of eating a healthy, balanced diet in order to replenish the body with nutrients from food. Plus, depending on the severity of the disorder, the person might need medical supervision to treat related problems, such as tooth erosion and heart arrhythmias. (Click here for information on developing healthier eating habits.)

It’s also necessary for the person to reestablish normal, healthy eating habits. This often includes planning and scheduling regular meals to determine what will be eaten and with whom. It also includes reintroducing foods that the person typically avoids back into the diet in a gradual manner, in order to end the cycle of avoidance and bingeing. (Click here for information on planning meals.)

3. Develop Coping Strategies

The next step is to develop coping strategies that can be used when a person feels the urge to binge, purge, or restrict food. It takes time and practice to develop coping strategies, but they can be very effective. Engaging in an enjoyable activity can help distract the person from urges to binge or purge. Using delaying tactics can put off the urges for an increasingly longer period of time. Coping phrases, such as “Healthy eating will make me feel better in the long run,” can often give the person motivation to resist an urge. Making a safety plan can help the person cope with high-risk situations that often lead to bingeing and purging. Forming new habits can help the person engage in healthier, alternative activities. Creating a healthier living environment and shopping for food in a smarter way can limit the number of triggers that lead to bingeing and purging. And learning mindfulness can often help the person choose healthier responses during urges, rather than just reacting in a habitual way. (Click here for information on developing coping skills.)

4. Challenge and Correct Self-Defeating Thoughts

The core of the CBT treatment for bulimia is to challenge and correct negative thoughts about self-image, food, and weight. These thoughts are often the cause of anxious, sad, and hopeless feelings. At the most observable level are automatic thoughts. These are critical thoughts that people think and say to themselves that sabotage success and happiness. Two examples of automatic thoughts might be “I’m too fat” and “If I were thinner, my life would be better.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels anxious, sad, or hopeless. (Click here for information on identifying automatic thoughts.)

Much of the CBT treatment for bulimia will be spent identifying and reevaluating these types of thoughts. This can be done with the use of a thought record. People with bulimia often struggle with distressing thoughts about food, weight, and their self-esteem. The thought record helps them look for evidence that both supports and contradicts these thoughts. Then, most importantly, it helps them create a more balanced thought. For example, if the person struggling with bulimia had the thought “I’m too fat,” the thought record would offer evidence of this thought being true and examples of it not being true in his or her life.

The thought record also helps the person identify different types of cognitive distortions, or unhelpful thinking styles. People with bulimia often have rigid, unrealistic standards that they use to measure their self-worth. Unhelpful thinking styles often support these unhealthy standards and therefore must be challenged and reevaluated, too. For example, a woman who catastrophizes might think that her life will be a complete failure unless she’s the perfect weight, while a man who uses emotional reasoning might believe that he is useless because he feels unhappy. (Click here for information on identifying cognitive distortions.)

By evaluating the evidence and cognitive distortions, the goal of the thought record is to help the person find new, healthier thoughts and ease feelings of anxiety, sadness, and hopelessness. In the above example, perhaps a more balanced thought would be “Even though I sometimes think I’m useless, I often do a lot of things that I’m good at.” And instead of feeling excessively anxious, such as 8 on a scale of 1 to 10, perhaps this newer thought will help the person feel less anxious, say only a 5 out of 10. (Click here for instructions on using a thought record.)

As the work on challenging automatic thoughts continues, a person using a thought record will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make a person more vulnerable to bulimia. These core beliefs, often called schemas, include thoughts like “I’m defective,” “I’m worthless,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought record and other techniques. (Click here for instructions on challenging core beliefs.)

5. Develop a Healthier Body Image

The next step is to challenge habits that make a person feel worse about his or her body and to explore new ways of creating a fulfilling life. The truth is that most people are not 100 percent happy with their weight or the way they look. But for the person struggling with bulimia, these thoughts often interfere with creating a healthy, fulfilling life. People with bulimia often put their lives on hold while they wait for their lives and their weight to reach a state of perfection, which never happens. Therefore, it’s very important for people with bulimia to start engaging in meaningful activities based on their values, despite the fact that their lives aren’t already perfect. (Click here for instructions on developing values and goals.)

It’s also important for people with bulimia to stop engaging in activities that make them feel worse about their bodies. This includes avoiding television, movies, and magazines that trigger self-critical thinking; avoiding behaviors such as weighing oneself and frequently checking one’s appearance in the mirror; and eliminating self-critical labels. (Click here for instructions on developing a positive body image.)

6. Increase Self-Esteem

Self-esteem is the value people put on themselves, based on both facts and the opinions of themselves and others. Unfortunately, people with bulimia often have very low self-esteem because they usually focus on negative, self-defeating evaluations and disregard positive evaluations. Luckily, there are many skills and techniques that help increase self-esteem. These skills include modifying perfectionism, being mindful of the labels used to describe oneself, challenging self-critical thoughts, developing self-compassion, making a more accurate self-assessment, avoiding the “shoulds,” reframing past mistakes, using assertive communication skills, and practicing visualization. (Click here for skills to increase self-esteem.)

7. Develop Emotion Regulation Skills

Emotion regulation skills serve a number of different purposes in the treatment of bulimia. They help people identify their emotions more clearly and easily, and help them cope with painful emotions instead of getting overwhelmed by them. People with bulimia often try to control or avoid undesirable emotions, like anger, frustration, and sadness. Part of the CBT treatment for bulimia involves developing an acceptance of these feelings and learning how to express them in appropriate ways. Emotion regulation skills also help people reduce their vulnerability to overwhelming emotions, increase their experiences of positive emotions, and learn to be mindful of emotions without judging them. Skills such as emotion exposure techniques can help people learn not to fear their feelings. Learning to do the opposite of emotional urges blocks ineffective, emotion-driven responses to situations. And, finally, problem-solving skills can help people develop coping strategies for events that trigger difficult emotions. (Click here for instructions on how to use emotion regulation skills.)

This stage of treatment might also include the development of interpersonal effectiveness skills. These skills can help people with bulimia learn how to express their thoughts and feelings in effective ways that help them get their needs met. Mindful attention skills are useful for recognizing how others are feeling and creating more satisfying relationships. Assertive communication and listening skills are also powerful interpersonal tools. These skills can help people get their needs met, set limits with others, learn how to say no, and negotiate for what they want. (Click here for instructions on how to use interpersonal effectiveness skills.)

8. Treat Related Problems

As stated above, many people struggling with bulimia also struggle with related problems, such as post-traumatic stress disorder (which is often the result of being abused), depression, and anxiety. As the treatment of bulimia progresses, these issues also must be treated. (Click here for information on the treatment of post-traumatic stress disorder, depression, and anxiety.)

It’s especially important to deal with any self-harming or impulsive behaviors that the person might engage in, as well as any self-destructive behaviors that involve alcohol or illegal substances. This can often be accomplished by identifying the situations that trigger these behaviors, recognizing the consequences of these behaviors, and then engaging in healthier, alternative behaviors. Problem-solving techniques can also be helpful for identifying these alternative behaviors. (Click here for instructions on managing injurious behaviors.)

Distress tolerance skills can also help a person cope with self-injurious and impulsive behaviors. Distraction techniques, like engaging in pleasurable activities or paying attention to someone else, can temporarily help a person stop thinking about something painful and therefore allow the person to choose a healthy way of coping. Self-soothing techniques, like taking a warm bath or listening to pleasant music, use the five senses to bring peace and relief from anxiety and pain. With practice, visualization and relaxation techniques, like cue-controlled relaxation, can also quickly create a sensation of peace. Making committed actions and connecting with a sense of higher power can make life more fulfilling and meaningful. Radical acceptance is a very important distress tolerance skill that will help people with bulimia reexamine painful situations so that they can stop fighting and judging painful situations that can’t be changed. (Click here for instructions on how to use distress tolerance skills.)

9. Prevent Relapse

Finally, the last step of the CBT treatment for bulimia is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of returning bulimia, in order to take steps to prevent relapse. (Click here for instructions on preventing relapse of bulimia.)

ACCEPTANCE AND COMMITMENT THERAPY FOR BULIMIA NERVOSA

Acceptance and commitment therapy (ACT) incorporates elements of behavior therapy, meditation and mindfulness practices, and scientific research on how humans think and learn.

ACT (pronounced “act”) is based on the principle that many psychological problems are caused by efforts to control, avoid, or get rid of emotions and thoughts that are undesirable. Often, people try to get rid of feelings and thoughts that make them sad or anxious, just as they get rid of other things they don’t want, such as old clothes. However, as ACT points out, feelings and thoughts can’t be controlled. A person can’t throw them out like an unwanted pair of shoes. In fact, the harder a person tries to control his or her thoughts and feelings, the more powerful they often become and the longer they stick around.

The ACT treatment for bulimia might include eight steps:^{43, 44}

Educate about bulimia and ACT
Develop creative hopelessness
Focus on contact with the present moment
Utilize cognitive defusion
Develop acceptance
Clarify values
Commit to taking action
Stay committed to values and actions

1. Educate About Bulimia Nervosa and ACT

The initial step of the ACT treatment for bulimia is education. It’s important to educate the person and the person’s family members about bulimia and the nature of emotions like anxiety and sadness. It’s especially important for the person with bulimia to understand the nature of these things from an ACT point of view. According to this treatment, food, weight, anxiety, and sadness are not the causes of bulimia. Rather, it’s the person’s attempts to avoid and control certain emotions and thoughts that make bulimia an overwhelming problem. Starting with the early stages of treatment, it’s also important for everyone involved to understand that ACT is an active, participatory treatment designed to help the person live a more fulfilling life, not necessarily a “happier” one. (Click here for more information about acceptance and commitment therapy.)

2. Develop Creative Hopelessness

In order to develop what ACT calls “creative hopelessness” a person must conduct a thorough evaluation of the strategies that he or she has already used to cope with anxiety and sadness. After doing this, the person often recognizes that all of these strategies have been unsuccessful or actually made the problem worse. This is because these strategies are actually attempts to avoid and control feelings of anxiety and sadness, which can never be successful. For example, a woman who attempts to control her anxiety about her weight by further bingeing and purging actually develops a worse problem, as does a man who tries to avoid his sad feelings about his food choices by purging after he has eaten. But rather than just being hopeless, this stage of treatment is also creative because it allows the person to begin exploring new, more successful ways of coping with anxiety and sadness. (Click here for instructions on how to develop creative hopelessness.)

3. Focus on Contact with the Present Moment

Focusing on what’s happening in the present moment can help people develop more flexible coping strategies for handling anxiety and sadness. When people dwell on the past, they often become sad, and when they anticipate the future, they often become anxious. In both cases, they miss what’s happening at the present time. Paying attention to what’s happening in the moment, gives people more control over the decisions they’re making and allows them to see more possibilities in life. This skill is often developed with present-focused mindfulness skills, such as focusing on the rising and falling of the breath or on physical sensations in the body. (Click here for instructions on how to develop present-focused mindfulness skills.)

4. Utilize Cognitive Defusion

Cognitive defusion is a mindfulness technique that helps people observe their anxious and fearful thoughts without becoming attached to them. “Defuse” is an invented word that means to unstick or to unfuse one’s self from the words that arise in thoughts. The goal of this stage of treatment is to allow people with bulimia to function more freely without judging themselves, their feelings, or their thoughts. Thoughts and emotions often arise haphazardly, so it’s easy to see that bulimia could worsen over time if a person were to follow or believe every thought and emotion that arose.

Cognitive defusion is often accomplished using meditation or mindfulness techniques, such as imagining thoughts floating by on a cloud, repeating the words of a thought over and over until they lose meaning, or imagining a thought as something outside of oneself. By observing the process of thinking and feeling, the goal is to create space between the person and his or her experience. This gives the person more control over decisions made based on those thoughts and feelings. (Click here for instructions on how to develop cognitive defusion skills.)

5. Develop Acceptance

In ACT, learning to accept frustrating situations and distressing emotions is the alternative to trying to control or avoid them. Acceptance can be hard, but it’s often the only way people can reclaim control of their lives. Many situations cannot be altered, no matter how much a person wishes them to be changed. Accepting this fact is often the first step in reengaging with life. Accepting what cannot be changed frees a person from struggling against it and allows that person to start taking actions based on what he or she values in life.

In order to cultivate acceptance, people are encouraged to experience the distressing emotions that they have been avoiding, to cease fighting things that cannot be altered, and to engage in situations that have been evaded. (Click here for instructions on how to develop acceptance skills.)

6. Clarify Values

ACT acknowledges that life is often lived on autopilot, without much sense of what a person really cares about. Clarifying and establishing what a person values can often help that person live a more fulfilling life, despite having occasional feelings of anxiety or sadness. Values are the elements of life that give it meaning and importance, like “maintaining relationships with my friends” or “being an active member of my community.” These values are like compass headings that guide a person through life. They are not destinations at which a person can ever arrive. A person can never stop maintaining a relationship and still have a caring relationship. Values are concepts that point a person in the direction of a fulfilling life, and ACT uses many types of values clarification tools to help people identify their values. (Click here for instructions on how to clarify and establish values.)

7. Commit to Taking Action

After a person has determined his or her values, it’s important to establish goals that support those values and then commit to taking actions that fulfill those goals. For example, if a woman’s value is to reconnect with her friends, she might list a number of different goals to fulfill that value, such as “call them twice a week” and “schedule more activities with them.” These are goals that can be completed and thereby create a sense of valued living. The ACT treatment for bulimia includes development of skills and goals that lead to taking committed action. (Click here for instructions on how to commit to taking action.)

8. Stay Committed to Values and Actions

Finally, in order to create a fulfilling life, it’s crucial for people to continue making decisions based on what they value in life, rather than based on the thoughts and feelings they have tried to avoid in the past. (Click here for instructions on how to stay committed to values and actions.)

INTERPERSONAL THERAPY FOR BULIMIA NERVOSA

Interpersonal therapy (IPT) was developed in the 1980s as a short-term, structured treatment for depression. In some cases, IPT treatment may last for only twelve to sixteen sessions. However, longer treatment is often necessary.

IPT helps people explore how bulimia is affecting their relationships, as well as how those relationships are contributing to their bulimia. Relationships with romantic partners, family members, friends, and coworkers are all equally important in IPT and need to be examined. It might also be necessary to explore what was happening in the person’s life when the bulimia developed. But because of the time-limited nature of IPT, little emphasis is placed on exploring a person’s past beyond how it might be currently affecting his or her relationships.

The interpersonal therapy treatment for bulimia includes four steps; however, not all the steps are easily adaptable to self-help models of treatment. The second, third, and fourth steps might require the help of a mental health care professional.

Based on the interpersonal treatment for depression, the interpersonal treatment for bulimia often includes five steps:^{45, 46}

Conduct an assessment and provide education
Make an interpersonal inventory
Take on the “sick role”
Define the focus of treatment
Work through the problems

1. Conduct an Assessment and Provide Education

The first step is to conduct an initial assessment of the person’s symptoms in order to verify that he or she is struggling with bulimia and not some other similar problem. Once people have been diagnosed with bulimia, it’s also important that they understand the basic nature and causes of the disorder (as highlighted above).

2. Make an Interpersonal Inventory

The second step is to help the person make an interpersonal inventory. The interpersonal inventory is a diagram or a list of all the important people in the life of the person struggling with bulimia. This includes people from both the past and the present. Creating an interpersonal inventory is an important first step in identifying both the number and the quality of a person’s relationships. This will help later in mending strained relationships and building better social support. (Click here for instructions on creating an interpersonal inventory.)

3. Take on the “Sick Role”

The third step is for the person with bulimia to take on the “sick role.” This means that the person acknowledges that he or she is dealing with a real illness, just like diabetes or cancer. The goal is to help people with bulimia stop blaming themselves for being sick and for not living up to their own or other people’s expectations. Defining the sick role in this way will hopefully free them up from other responsibilities and allow them to focus on taking care of themselves. (Click here for help with taking on the sick role.)

4. Define the Focus of Treatment

The fourth step is to define the focus of treatment, whether it’s grief, interpersonal disputes, role transitions, or interpersonal deficits. When working in a time-limited treatment, it’s acknowledged that not all of a person’s problems can be addressed. It’s therefore beneficial for the person to focus on one specific area of his or her life in treatment. (Click here for instructions on how to choose a focus of treatment.)

5. Work Through the Problems

Finally, the fifth and last step is to work through the problems in the defined focus of treatment. This begins by helping people link their problems with bulimia to some interpersonal event that they have experienced. IPT generally focuses on four causes of distressed feelings: role disputes, grief, life transitions, and skills deficits.

When a person’s bulimia is caused by disputes and disagreements with others, the goals of treatment include learning how to negotiate and communicate in more effective ways. When bulimia is caused by grief for a loved one who has passed away, treatment includes the exploration of feelings for that person and reengaging with other people.

Changing roles in life can also cause bulimia, as it sometimes does during divorce, the development of an illness, or changing jobs. If this is the case, IPT can help the person explore his or her feelings about loss of the old role and identify new skills that are needed in the new role. And, finally, sometimes people experience bulimia because they don’t have skills to cope with issues like loneliness and isolation. In these cases, IPT can help people expand their social support network and learn other needed skills, such as assertive communication skills to handle interpersonal situations. (Click here for instructions on how to develop interpersonal skills.

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