BOOK REVIEW: Coping Strategies Therapy for Bulimia Nervosa
Reprinted from Eating Disorders Review
November/December 2000 Volume 11, Number 6
©2000 Gürze Books
(By David L. Tobin. Washington, DC: American Psychological Association, 2000. 272 pp; $39.95)
In this scholarly, provocative, and thoughtful book, David Tobin, a clinical psychologist with a strong research background, pushes us to think beyond cognitive behavior therapy (CBT), interpersonal psychotherapy, and supportive-expressive therapy, those manual-based modalities for the treatment of bulimia nervosa for which current empirical studies exist. Dr. Tobin leads us to more comprehensive forms of psychotherapy that are tailored to individual differences and needs.
Coping strategies therapy stresses the importance of assessing each individual's state of readiness for change and co-morbidities, then individually fitting the psychotherapies to these clinical realities. Coping strategies therapy recognizes and uses the contributions of the currently available evidence-based, manual-aided therapies, but goes further. Since CBT and interpersonal therapy assume that the patients being treated are, in fact, ready for change, a large number of patients in the real world, who are not yet sufficiently motivated, may not be able to take advantage of or to benefit from them. Trying to engage patients in these active treatments prematurely may lead to a waste of time and resources.
Besides incorporating the valuable elements of CBT and other proven therapeutic modalities, coping strategies therapy rests on three additional basic pillars. The first pillar is the transtheoretical model, focusing on motivational states, based on the studies and theories of Prochaska and others, which have been so influential over the past two decades in treatments for alcoholism, substance abuse, and other disorders requiring behavior and lifestyle change. The second pillar is the dose-effect "theory" of Howard and others, showing that the outcomes of psychotherapy for certain problems are clearly related to the number of sessions (and possibly the duration of time) over which the therapy is administered. The third pillar is coping theory, starting with the work of Lazarus and Folkman, and extended by many others, including Tobin's own work. Coping theory incorporates constructs of problem-focused and emotion-focused coping and levels of engagement and disengagement with problems and emotions.
Tobin labels various aspects of treatment as "doses." The book details the "doses" of therapy (focus and number of sessions) that are appropriate for individuals in different stages of motivation (pre-contemplation, contemplation, preparation or action), and illustrates the use of those doses in individuals who tend to use each particular form of coping. The first three doses are very similar to Fairburn's descriptions of his now-classic CBT. To this Tobin adds "dose 4," taking from 50 to100+ sessions, aiming to resolve more deeply ingrained emotional dysregulation, maladaptive interpersonal patterns, and environmental contingencies. This usually involves a focus on the therapeutic relationship as well as other psychotherapeutic strategies, i.e., longer-term psychotherapy.
What distinguishes Tobin's program from others is, in part, a description of criteria for suitability for each of the doses. Dose 1 involves a diagnostic stage of 1-2 sessions, suitable for all. The assessment process is very well described, and I highly recommend this discussion to clinicians. Tobin then defines the types of patients he sees as suitable for moving on to dose 2, involving self-management skills training, usually occurring in sessions 3-8. To benefit, patients should be at least at the preparation stage of motivation. The presence of severe personality disorders, very low or very high weights, bipolar affective disorder, psychosis, or substance dependence may preclude suitability. Dose 3 involves a variety of interventions designed to increase coping skills using cognitive, focal, dynamic, interpersonal and relational approaches and may take up to session 20 sessions. Dose 4 is suitable for patients with urgency or crisis who manifest long-term maladaptive personality and interpersonal problems, substance abuse, and/or medical instability, and who may be in a pre-contemplation stage.
The emphasis is on active and attentive psychotherapies, but there are no new therapeutic strategies offered here. Rather, the basic assumption is that in a truly integrative manner the clinician will strive to use the right strategy for the right person at the right time. Tobin provides a large number of clinical examples and vignettes to illustrate these concepts. Given the wide array of potential choices for potential patients, Tobin can only provide guidelines; it's impossible to reduce this "therapy" to a simple manual.
Tobin addresses the shortsightedness of managed care insurance coverage that doesn't take the patient's true needs into account and that push treatments which may not be suitable. He suggests that by individually tailoring the best treatment for the individual, costs of care may be less in the long run. The therapy programs he describes are not interminable.
Although many readers may find some statements in the book to be controversial and even opinionated, on the whole the effort is very valuable. Individual readers will have to judge how successful Tobin is in actually incorporating motivational analytic techniques derived from the transtheoretical model into these psychotherapies; I would have liked more emphasis on this point. Similarly, there's little discussion of family or couples therapies, which may be very helpful for some patients in comprehensive treatments. But, on the whole, these ideas are refreshing. They just need to be tested out in clinical trials. Like the aeronautical engineer said as he looked at the blueprints of a proposed new aircraft, "It looks good on paper—but will it fly?"