Group Schema Therapy for Eating Disorders: Study Protocol

By Calvert, Fiona; Smith, Evelyn et al. | Journal of Eating Disorders, January 9, 2018 | Go to article overview

Group Schema Therapy for Eating Disorders: Study Protocol


Calvert, Fiona, Smith, Evelyn, Brockman, Rob, Simpson, Susan, Journal of Eating Disorders


Author(s): Fiona Calvert[sup.1,2], Evelyn Smith[sup.2], Rob Brockman[sup.3] and Susan Simpson[sup.4]

Background

The treatment of eating disorders is a difficult endeavor, with only a relatively small proportion of clients responding to standard cognitive behavioural therapy (CBT). Less than half of those with bulimia nervosa (BN) have recovered at follow-up after receiving CBT [17, 18, 23] and research supporting cognitive-behavioural treatment for anorexia nervosa (AN) is limited, with no clear indication of improvement in this population [6, 8]. Approximately 50% of patients with eating disorders continue to be highly symptomatic at 60-week follow-up following transdiagnostic CBT [16]. Further, treatment dropout rates are high amongst individuals with eating disorders [9, 43] with one literature review reporting an average drop-out rate of between 20 and 51% in inpatient settings and between 29 and 73% in outpatient settings [20].

The treatment of eating disorders is especially complicated by a high level of co-morbidity [3]. Approximately 69% of individuals with eating disorders may meet DSM IV (APA, 1994) diagnostic criteria for a personality disorder and 93% of these clients may also have other co-morbidity including anxiety and substance use disorders. Eating disorders are also associated with the presence of rigid personality features, which increases clinical complexity and is associated with poorer treatment outcomes [22, 26, 46]. Eating disorders have also been linked to a range of trauma-related risk factors, including childhood abuse and neglect, which may also be mediated by personality disorder diagnoses [5]. Individuals with eating disorders also commonly experience complex and difficult-to-treat symptomatology including dissociation, perfectionism, compulsive pathology, rigid thinking patterns [28, 30, 38, 49] and high levels of shame [7].

Given the prevalence of co-morbidity and complex personality traits in this population, it is important to consider the deeper belief systems underlying eating disorder presentations. Schema Therapy ([53]/1999) is becoming an increasingly popular psychological model for working with individuals with complex mental health and personality difficulties. Schema Therapy combines aspects of cognitive, behavioral, experiential, interpersonal and psychoanalytic therapies into one integrative and unified model [1]. The schemas that are targeted in treatment are enduring and self-defeating patterns that typically begin early in life. These patterns consist of negative/dysfunctional thoughts and feelings which have been repeated and elaborated upon, and pose obstacles for accomplishing one's goals and getting one's needs met [40]. These schemas are perpetuated behaviorally through the coping styles of schema maintenance, schema avoidance, and schema compensation. The Schema therapy model of treatment is designed to help the person break these negative patterns of thinking, feeling and behaving and develop healthier alternatives to replace them [1].

The evidence for schema therapy for individuals with complex mental health difficulties is growing. This approach has been applied, in both individual and group forms, to a wide variety of clinical disorders, including, borderline personality disorder [19, 21] and chronic depression [11, 34, 41, 42]. A recent stringent systematic review found medium to large effect sizes for schema therapy in the treatment of a range of psychological conditions [35]. Attention has recently been given to the applicability of Schema Therapy to individuals with eating disorders (Pugh, 2015). Evidence suggests that maladaptive schemas are more strongly held by individuals with anorexia and bulimia nervosa compared to normal controls [30]. Preliminary data [33, 38] supports the notion that it is the schema processes that are engaged in an attempt to avoid intolerable emotional states associated with these schemas that in fact determine whether an individual will manifest restrictive or bulimic eating pathology. …

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