Coping Strategies Therapy for Bulimia Nervosa

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Summary: An integrative approach for the treatment of BN
Review: In coping strategies therapy (CST) for bulimia nervosa, the author brings together a range of models and theoretical assumptions (transtheoretical model, dose-effect theory and coping theory) that result in an interesting framework with the ambition of integrating these different strategies and approaches into a broad and effective treatment. The empirical evidence for these models and theories, as well as their application to BN is described in chapter one. The book is organized into two parts. In part one (comprising 3 chapters), the framework for CST is presented. Part two is devoted to the description of four doses of treatment (chapter 4-7) and some conclusions (chapter 8). By using the transtheoretical model, the intervention might be matched to an individual's readiness to change. This would reduce resistance, stress and time to implement a change by accelerating movement toward the action stage. As described in chapter 2, CST involves a range of therapeutic activities including education, self-management, problem solving, cognitive restructuring, or brief interpersonally and affectively charged interventions. Dose-effect theory where dosage reflects both the concentration and duration of treatment has been used to create a theoretical structure for organizing diverse approaches to treatment. There are four doses of therapy in CST: A 2-session dose, an 8-session dose, a 20-session dose and a dose of 50-100 or more sessions. The author suggests that the coping theory links dimensions of coping in a cohesive framework that is consistent with current models of psychotherapy for BN. Problem solving and cognitive restructuring reflects cognitive behavior therapy (CBT), social support and expressing emotions reflects Interpersonal psychotherapy (IPT) and brief psychodynamic therapy and the disengagement factors reflect dialectic behavior therapy (DBT), trauma therapy and expressive psychotherapy. In chapter 3, a multifactorial model for assessing individual differences among patients with BN is presented by using a combination of factor analytically derived constructs and transtheoretical model with an interpersonal model of development and trauma, based on object relation theory. The author provides very helpful guidelines from his clinical practice, and the result is an unusual mix of empirical findings and clinical theory. The four doses of therapy are described in chapter 4-7. The initial evaluation for all doses is described in chapter 4. Dose 1 is the smallest dose of the CST lasting 1-2 visits. The instillation of hope is the core clinical intervention in dose 1. The core strategies are the most basic of the active behavioral processes and the problem engagement dimension of coping. They include self-monitoring of eating pattern and symptoms and meal stabilization. Patients who are in preparation phase (according to transtheoretical model) with sufficient motivation for behavior change are candidates for dose 2 of CST. Dose 2 (3-8 sessions) is most likely to be successful with patients who have little or no comorbidity or have a relatively circumscribed comrobid condition. The core strategies in dose 2 are reinforcement management, self-monitoring, helping relationship, stabilizing meal patterns, examining eating records, promoting coping skills, counterconditioning, and stimulus control.Dose 3 involves use of experiential processes and emotion-focused coping for patients who are not yet ready to engage in active behavior change. The author suggests that dose 3 strategies are most consistent with experiential and interpersonal forms of therapy (e.g., IPT, supportive-expressive therapy, time limited psychodynamic therapy and client-centered therapy). Dose 3 patients are likely to be in contemplation stage and to require enhancement in their motivation for behavior change before taking action. Dose 4 treatment involves efforts by the therapist to reduce disengaged coping for patients who are not yet ready to engage in positive change processes and engaged coping efforts. Treatments for disengagement include expressive psychotherapy, treatment for dissociative disorders, trauma therapy, and cognitive therapy for patients with personality disorders as well as DBT, of which only DBT is empirically supported. Candidates for dose 4 are likely to be in precontemplation stage and those with serious comorbidity or/and very high/low Body Mass Index (BMI). In CST, different symptoms are targeted with different amounts of therapy and the techniques of therapy are affected by dosage of therapy. The author suggests that the analysis of transference and countertransference can be extremely useful at any dose of therapy if the situation is appropriate, but it is emphasized as most crucial for stage 4 treatment. An important limitation in justifying the theoretical framework of CST is that CBT is restricted to manual-based versions of this treatment, and the powerful utility of the functional analysis that is the fundamental basis for adapting the treatment for the individual patient in clinical practice has been ignored. Since all doses of treatment might be covered by various forms of CBT and DBT, the behaviorally oriented reader might ask himself/herself what is the point of using psychodynamic concepts (e.g., transference) in the approach. Nevertheless, the present book makes a significant contribution by showing the possibility of integrating several empirical models from both a theoretical, empirical and pragmatic point of view. It is a thought-provoking work that gives rise to many interesting hypotheses and hopefully some empirical research. I would like to recommend this book to all clinicians and researchers working with patients with eating disorders.