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Book Forum: Treatment Perspectives   |    
Coping Strategies Therapy for Bulimia Nervosa
PAULINE S. POWERS, M.D.
Am J Psychiatry 2002;159:1455-1455. doi:10.1176/appi.ajp.159.8.1455
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By David L. Tobin. Washington, D.C., American Psychological Association, 2000, 247 pp., $39.95.

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In this innovative and interesting book the author integrates many of the recent research findings for treatment of bulimia nervosa with well-known clinical observations of these patients. The main concept of this book is that patients with different coping styles and different comorbid diagnoses need different doses and types of treatment. The author provides a guide for choosing the appropriate treatment based on a hierarchy of defense mechanisms and assessment of readiness for treatment. Four possible doses of treatment are described, ranging from one or two sessions to more than 100 sessions. The importance of transference and countertransference issues is emphasized, including analysis of the transference in doses 3 and 4. For each dose of treatment, outstanding clinical examples are provided.

In section 1, the author describes the concept of coping strategies therapy. For example, in dose 1 of therapy, the patient is in the action stage of readiness for treatment, is using the coping strategy of problem engagement, and may need only one or two sessions of cognitive behavior therapy; the patient may be able to self-administer cognitive behavior therapy. Patients who require dose 2 are likely to be in the preparation stage of readiness for treatment, are engaged with the problem, and will probably benefit from 10 to 15 sessions of individual or group cognitive behavior therapy. Patients who require experiential processes before they can use active behavioral interventions require dose 3 of treatment, usually requiring about 20 sessions. Patients needing dose 3 are usually in the precontemplation phase of readiness for treatment and benefit from therapies that focus on self-esteem and interpersonal concerns; these patients often have some pervasive personality problems or trauma-related difficulties. Patients who are unable to form satisfactory attachments need to learn how to form a satisfactory relationship with the therapist in dose 4; this usually requires 50–100 or more sessions. Many of the principles of psychoanalysis are important in this dose of treatment, including analysis of the transference and recognition of countertransference issues. Patients requiring dose 4 are usually in the precontemplation phase of readiness for treatment.

Section 2 of the book provides detailed descriptions of each dose of treatment with illustrative case examples. The coping strategy of projective identification, typically seen in patients requiring dose 4 of treatment, is described particularly well. In projective identification the patient projects internal feeling states onto the therapist; this often evokes countertransferential responses that must be identified and managed for the patient’s benefit.

This outstanding book is a major step forward in explaining many of the confusing contradictions between well-publicized research findings on cognitive behavior therapy and the experience of the clinician working with bulimia nervosa patients who present with widely different problems. It is indeed heartening that the author retains many of the useful concepts and techniques of psychoanalysis and integrates them into current clinical strategies.

Reprints are not available; however, Book Forum reviews can be downloaded at http://ajp.psychiatryonline.org.

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