Schema therapy for anorexia nervosa : an intensive systematic individual case study
Authors:   , Alexander Graham 
Published: January 2022

Developed more than three decades ago, schema therapy (ST) was born out of a need for a more effective way of working with difficult and challenging cases where patients were clearly unresponsive to the existing short-term cognitive therapies. While anchored in the primary theoretical orientation of cognitive therapy, ST has carefully integrated techniques and principles from attachment and object-relations therapies, as well as humanistic, gestalt and experiential therapies. The mode model emphasises the concept of “multiplicity” in terms of which the self is functionally divided into parts or schema modes. For a little more than a decade there has been growing interest amongst researcher-clinicians in the application of ST for the treatment of eating disorders (EDs) (Waller, et al., 2007; Simpson, 2012; Edwards, 2015; Munro et al., 2016; Simpson, 2016; Munro et al., 2016). While multivariate studies can provide quantifiable evidence for the efficacy of ST for treating EDs, systematic case-based research offers a means of engaging in an intensive analysis and description of the complex and subtle processes that unfold over time in a real-life therapeutic environment (Edwards et al., 2004; Yin, 1994). This research method also provides an opportunity for the refining of the clinical treatment model as well as its testing. Ten participants were assessed and treated with schema therapy. However, because of the large amount of data gathered, a decision was made to write up only one as an intensive systematic individual case study. Alison, an elderly woman with a longstanding history of AN who had been largely unresponsive to considerable previous therapies, received 100 ST sessions over a two-year period and showed a very positive response. The many challenges that arose and the way these were addressed within the ST framework provide an in-depth account of the application of the ST mode model for the treatment of AN. This is presented in a detailed therapy narrative. After results of the quantitative measures are provided, the next three chapters address three interpretative questions pertaining to the Healthy Adult/Vulnerable Child dyadic relationship, the processes of working with the Angry Child mode, and the conceptualising of an AN-specific coping mode. Several conclusions are drawn about the strengths of the schema therapy model and its particular application to AN. Amongst these is the importance of having a comprehensive case conceptualisation that serves as a collaborative “road map” with which to negotiate the unfolding collaborative therapeutic process. Another is the identifying of the “Anorexic Overcontroller” as a stand-alone coping mode that clarifies the functions of AN to hinder schema-based emotional injury, but paradoxically, still denies the individual’s basic core needs being met. Such a conceptualisation significantly assisted in the suspension of anorexic behaviour. A further significant observation is how emotion-focused work (especially within the context of chair work and imagery) brought therapy to life and was particularly effective in mobilising the conflict between internal voices. Another outstanding feature is how the building of a strong Healthy Adult mode proved vital in the healing process and the development of patient autonomy. Finally, therapy revealed how central the establishment of a sturdy, warm and loving therapeutic relationship is, and how influential the resonance between the therapist and patient is in the outcome of treatment.