Schema Therapy for Eating Disorders

Theory and Practice for Individual and Group Settings

Susan Simpson, Evelyn Smith, Susan Simpson, Evelyn Smith

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781000186376
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Options can be limited for those who do not respond to standard eating disorder treatments. Schema therapy is one of the new exciting frontiers in the treatment of this clinical population, offering a much-needed model that integrates both developmental and deeper level personality factors. S chema Therapy for Eating Disorders is the first book of its kind, guiding clinicians to deliver the schema model to those with entrenched or enduring eating pathology, and in turn encouraging further clinical research on this approach to treatment.

Written by an international team of leading schema therapy experts, and with a foreword by Wendy Behary and Jeffrey Young, this book draws on their clinical knowledge and research experience. Comprehensive and practical, this book introduces the rapidly growing evidence base for schema therapy, outlines the application of this model across eating disorder diagnostic groups, as well as individual and group modalities, and explores practical considerations, common challenges and the therapeutic process. The book includes detailed case examples, which provide a theoretical and practical basis for working withtherapist-client schema chemistry and transference, and outlines methods of ensuring therapist self-care in the face of difficult and often long-term work.

Innovative and accessible, this fresh look at the treatment of eating disorders will be an invaluable resource for clinicians in the field.

Part I

Introduction to schema therapy

Chapter 1

Introduction to schema therapy for eating disorders

Evelyn Smith, Susan Simpson and Virginia V. W. McIntosh

Abstract

Given the limited efficacy of maintenance models such as cognitive behavioural therapy (CBT) in the treatment of eating disorders (EDs), there has been increased attention dedicated to exploring the role of deeper level factors such as core beliefs and schemas in the eating disorders literature. One model, which integrates both developmental and deeper level personality factors, is the schema model developed by Jeffrey Young (1990; 2003). Schema therapy (ST) has shown promising outcomes in recent randomised trials for a range of personality disorders and other complex psychological problems. On this basis it appears to be ideally suited to working with the ED population. This chapter introduces the reader to what ST is, highlighting the most prevalent modes in this population, and articulating why this treatment should be considered as a second line of treatment for adults with eating disorders who either have not responded to CBT or have stopped making progress. The aim of this book is to encourage further clinical research on the schema mode model, and to guide individuals to deliver ST for EDs confidently and successfully.

EDs have the highest mortality of any mental illness, however recovery is possible with treatment. The evidence-base supporting psychological treatments for EDs has grown exponentially in the past decade, with a large proportion of individuals experiencing significant improvements. Nevertheless, in clinical settings, we often encounter ED presentations that do not fit into our standard protocols, and patients who do not engage in, nor respond to, our best treatments. Indeed, it is well recognised that the treatment of EDs can be fraught with complexity, and that a proportion of individuals develop a picture characterised by chronicity and ego-syntonicity (i.e. ‘my anorexia defines who I am’) (Bardone-Cone, Thompson, & Miller, 2018).

There are a significant number of individuals with EDs who do not respond to our first line treatment, namely CBT. Indeed, attrition (Fassino, Pierò, Tomba, & Abbate-Daga, 2009) and relapse rates are relatively high (Grilo et al., 2012) with a substantial proportion of EDs presenting as chronic, disabling and resistant to treatment (Steinhausen & Weber, 2009; Abbate-Daga, Amianto, Delsedime, De-Bacco, & Fassino, 2013). While enhanced CBT (CBT-E) has led to improved outcomes for those with bulimia nervosa (BN) and binge eating disorder (BED) there still remain approximately 40 to 50% of individuals who do not respond to treatment (Fairburn et al., 2009; Byrne, Fursland, Allen, & Watson, 2011). In one recent study, at two years post-CBT-E, 44% of those with BN were found to be abstinent, whilst over half remained symptomatic (Poulson et al., 2014). Anorexia nervosa (AN) in particular remains difficult to treat, with CBT (and CBT-E) outcome trials reporting relatively high drop-out rates and limited efficacy (Hay, 2013). For those with severe and enduring AN, outcomes have been generally poor, with only a handful of outcome studies in the area. Whereas many clients become experts in identifying thinking errors and challenging their own negative thoughts and beliefs, they often describe limited changes to their deeply held core beliefs (Leung, Thomas, & Waller, 2000; Jones, Leung, & Harris, 2007) that are often experienced at a visceral or ‘felt-sense’ level (Simpson, 2012).

There is a relatively high prevalence of suicidal behaviour amongst those with EDs, with at least 25% engaging in self-harm (Sansone & Levitt, 2002). Comorbidity has been found to play a significant role in predicting treatment engagement and effectiveness. It is estimated that 58–69% of individuals with EDs meet a diagnosis for personality disorder, with up to 93% experiencing another disorder, including affective disorders, anxiety disorders and substance misuse (Rosenvinge, Martinussen, & Ostensen, 2000; Blinder, Cumella, & Santhara, 2006; Farstad, McGeown, & von Ranson, 2016). Preliminary evidence suggests that the presence of rigid personality pathology (e.g. perfectionism, narcissistic defences) and personality disorder (PD) (particularly avoidant and obsessive-compulsive PDs) may adversely affect treatment outcomes (Masheb & Grilo, 2008; Pham-Scottez et al., 2012; Zerwas et al., 2013). In addition, a range of personality traits have been found to be highly correlated with ED symptom severity and negative treatment outcomes, including impulsivity, compulsivity, avoidance motivation, and affective instability (Farstad et al., 2016). Of particular note, perfectionism is reported at high levels across ED diagnostic groups (Bardone-Cone et al., 2007) and is positively correlated with ED symptomatology. The majority of research suggests that standard treatments are not consistently effective in addressing perfectionism both for those with AN and BN (Aguera et al., 2012; Segura-Garcia et al., 2013).

There is a clear need for innovative transdiagnostic treatment models that are sufficiently sophisticated to address eating pathology, alongside characterological traits, affective instability, and other comorbidities in a focused, integrative and intensive way (Wilson, Grilo & Vitousek, 2007; Cooper & Kelland, 2015). Preliminary evidence suggests that schema therapy may be well suited to the treatment of EDs, particularly those with high complexity and comorbidity, and symptoms that are unresponsive to first-line treatments (Simpson, Morrow, van Vreeswijk, & Reid, 2010; Simpson & Slowey, 2011; McIntosh et al., 2016). A range of studies have demonstrated that ST is an efficacious and cost-effective treatment for borderline personality disorder (BPD) (Giesen-Bloo et al., 2006; van Asselt et al., 2008; Farrell, Shaw, & Webber, 2009; Nadort et al., 2009; Masley, Gillanders, Simpson, & Taylor, 2012), Cluster C personality disorders (Bamelis, Evers, Spinhoven, & Arntz, 2014), as well as a range of other disorders including substance misuse (Ball, Maccarelli, LaPaglia, & Ostrowski, 2011), depression (Carter et al., 2013), post-traumatic stress disorder (Cockram, Drummond, & Lee, 2010), panic disorder and agoraphobia (Gude & Hoffart, 2008).

Introduction to schema therapy

ST is an integrative model, drawing on CBT, psychodynamic, gestalt, constructivism, and attachment models. It was originally designed for chronic, personality-related problems, and departs from CBT by conceptualising childhood and adolescent experiences at the origins of psychological problems. ST also differs from traditional CBT in the emphasis it places on the therapeutic relationship, the use of emotion-related therapy strategies and its focus on schema-driven maladaptive coping styles. The ST model comprises four constructs: early maladaptive schemas (EMS), schema domains, schema processes, and schema modes (Young, Klosko, & Weishaar, 2003), which are summarised below.

Young’s conceptualisation of schemas differs from that of earlier cognitive theorists (Beck, Rush, Shaw, & Emery, 1979). Young’s schema concept is an organising system or pattern, which includes thoughts, memories, emotions, physical sensations, and drives. EMS create self-defeating patterns and are central to an individual’s core psychopathology (Young et al., 2003). See Appendix 1 for a list and brief description of all 18 EMS.

Schemas are theorised to develop when core emotional needs of childhood are not met, including the need for secure attachments to others; autonomy, competence, and a sense of identity; freedom to express valid needs and emotions; spontaneity and play; and realistic limits and self-control. Core needs may be unmet when the early environment is toxic or when there is a mismatch of the environment and the child’s temperament. The nature of the adversity experienced during childhood relates directly to the types of EMS that may develop. For example, when a child experiences trauma or victimisation, schemas such as mistrust/abuse or defectiveness/shame may develop. If the childhood environment is deficient in warmth, nurturance, understanding, love or stability the child may develop schemas such as emotional deprivation or abandonment. On the other hand, if the child is overindulged or overprotected, experiencing too much of what would be healthy in moderation, schemas such as entitlement/grandiosity or dependence/incompetence may develop. Such early experiences are theorised to contribute to the development of schemas, which in turn drive the problems of later life, including binge eating and restriction.

ST’s main goal is to heal EMS, which involves the diminishment of emotion, thoughts, bodily sensations and memories connected with the schema, reduction of maladaptive coping styles that the individual uses to avoid or cope with EMS, and development of new coping styles of behaviour that are adaptive and enable current unmet needs to be addressed (Young et al., 2003).

EMS are hypothesised to be extremely stable and enduring themes that develop during childhood and are elaborated upon throughout a person’s lifetime. Schemas serve as templates for the processing of later experience. They are unconditional, self-perpetuating, and very resistant to change. Established early in life as a relatively adaptive response to the individual’s environment, schemas may become maladaptive over time, in different contexts or with changed circumstances. When EMS are triggered, schema processes are employed to avoid or reduce negative affect associated with schema activation (Sheffield, Waller, Emanuelli, Murray, & Meyer, 2009). The three schema coping processes include surrender (passive acceptance of schemata); avoidance (blocking and avoiding schemata and associated emotions and situations); and overcompensation (fighting schemata by doing the opposite) (Luck, Waller, Meyer, Ussher, & Lacey, 2005).

Schema modes are defined as ‘those schemas or schema operations – adaptive or maladaptive – that are currently active for an individual’ (Young et al., 2003: p.37). The schema mode concept is broader than that of EMS and incorporates both EMS and schema processes into a unified construct (Young et al., 2003). Schema modes are state constructs that are triggered when trait-based EMS are activated and are consequently strongly influenced by the individual’s current affective state and situational context (Young et al., 2003).

The concept of schema modes was developed to account for more complex presentations, whereby multiple schemas and coping styles are collapsed into different ‘sides’ of self. Schema modes represent the moment-by-moment states that an individual experiences. Young et al. (2003) report the presence of four schema mode categories: dysfunctional child modes that result from unmet childhood needs; parent modes which encapsulate the internalisation of parental behaviour toward the child; dysfunctional coping modes which correspond to the schema processes of avoidance, overcompensation and surrender; and the adaptive healthy modes which refer to the individual’s functional and adaptive thoughts, feelings and behaviours and ability to act in a playful and spontaneous manner (Lobbestael, Van Vreeswijk, & Arntz, 2008). Modes include the Vulnerable Child, Angry Child, Impulsive Child, Punitive or Demanding Parent, Detached Protector, Overcontroller, Happy Child, and Healthy Adult. The experience of individual schemas can change very quickly, and the idea of being ‘stuck in’ one schema mode, or ‘flipping between’ schema modes can be particularly important for individuals with high complexity and comorbidity. Understanding which life events result in activation or triggering of schema modes becomes part of the work of healing in a schema modes therapeutic approach. For a description of each mode usually found in those with EDs, see Chapter 4, Box 4.1, page 46.

Rationale for using schema mode therapy for adults with EDs

Evidence suggests that those with EDs are distinguishable from non-clinical populations both through significantly higher levels of EMS (Damiano, Reece, Reid, Atkins, & Patton, 2015) and schema modes (Talbot, Smith, Tomkins, Brockman, & Simpson, 2015). Further, difficulties associated with parental bonding and early attachment have been shown to mediate the relationship between EMS and ED symptoms (Deas, Power, Collin, Yellowlees, & Grierson, 2011; Brown, Selth, Stretton, & Simpson, 2016). Indeed, a disproportionately high rate of those with EDs have suffered childhood sexual, physical or emotional abuse (Brewerton, 2007), with clear indications that traumatic exposure is associated with self-reported severity of ED symptoms, higher secondary psychosocial difficulties, psychiatric comorbidity, and negative self-image (Backholm, Isomaa, & Birgegård, 2013).

In recent years, ST has been further developed into group treatment protocols. Evidence suggests that group therapy may in fact catalyse the effects of ST, by providing corrective emotional learning experiences, as well as a forum in which participants can begin to develop and practice new interpersonal and behavioural coping skills that heal their schemas. In addition, the experience of sharing similar experiences and schemas with other participants can counteract the experience of shame and powerlessness that many clients with EDs experience. This setting also provides ample opportunities to learn vicariously through others (Farrell et al., 2009; Simpson et al., 2010; van Vreeswijk, Spinhoven, Eurelings-Bontekoe, & Broersen, 2012).

The development of the schema mode model in recent years has facilitated a state-based conceptualisation of eating disordered behaviours, which is particularly useful in the context of complex comorbidity and characterological difficulties (Simpson, 2012). ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of illustrations
• List of contributors
• List of abbreviations
• Foreword
• Acknowledgements
• PART I: Introduction to schema therapy
• PART II: Schema therapy assessment and case conceptualisation
• PART III: Application of schema therapy to eating disorders
• PART IV: Challenges when doing schema therapy
• PART V: The future of schema therapy
• Index