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Anorexia Nervosa (AN) is a serious disease and is one of the most common life-threatening psychiatric conditions. AN typically appears in adolescence, on average at the age of 17 (Carpine et al., 2021). According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013), the diagnosis of AN is defined by the following three criteria: 1) restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health; 2) intense fear of weight gain or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight; and 3) disturbance in a way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. A diagnosis of AN can be subdivided into two distinct subtypes, the restricting subtype and the binge-eating/purging subtype Adolescent AN has a significant and long-standing impact for the health and well-being of young people and their families. The determinants of illness are multi-factorial, however, adolescent AN has been consistently associated with parental distress (e.g., depression, anxiety, alcoholism), family conflict, and low parental warmth toward the adolescent. Whilst Family Based Therapy (FBT) for adolescent AN is the recommended first line of treatment, a substantial proportion of patients do not experience remission by the end of therapy or may relapse following remission. Up to 27% of these families discontinue these family-based psychotherapeutic interventions with higher drop-out rates most frequently occurring in the early phase (i.e., the first 2–3 months) of longer treatment interventions over 12 months (DeJong et al., 2012). A higher drop-out rate of 21.4% has been found for FBT than for individual therapy for adolescent AN (Lock et al., 2010). Although a range of adjuncts to FBT have been proposed, no preferred model has emerged. Therefore, further research is needed into a greater diversity of interventions for adolescent AN, develop efficacious alternative models to help those who do not attain or maintain full remission. Schema Therapy (ST) was developed more than three decades ago, emerging from a trend towards the development of more integrative therapies. Jeffrey Young’s development of ST was driven by his interest in cultivating a more effective way of working with difficult and challenging cases in which patients were clearly unresponsive to the existing short-term cognitive therapies. Anchored in an adaption of cognitive therapy, he carefully integrated techniques and principles from other well-established frameworks such as attachment based and object-relations therapies, as well as Gestalt and experiential therapies. More recently, ST has caught the interest of clinicians and researchers in the eating disorders (EDs) field seeking more effective treatment than those currently most recognised and practiced. In light of the many personality, interpersonal and other adjunct psychological problems experienced amongst patient with EDs, it is Simpson (2019) who has developed a ST mode model for this psychiatric population. Amongst other researchers, she has observed the most common EMSs and schema modes evident within this psychiatric population; observing the interplay and sequences of child, adult, coping modes, and appreciating the centrality of the therapeutic relationship to facilitate change. Furthermore, the impact of family context on AN individual's schema development is revealed through studies showing associations between parenting styles received during childhood and EMSs reported later in life. Research suggests that attachment issues may provide a reasonable guide for developing EMSs (Gibson & Francis, 2019). Since EMSs persist into adulthood, and comprise of strongly held relational themes, EMSs of parents might be expected to impact the relationship with their child. Similar to Systemic approaches, Schema Therapy aims to change the way people talk in their family. Understanding schemas and mode interactions makes it easier for family members to get a new perspective. Unlike in systemic therapy and FBT, in schema therapy the AN is not externalized and given negative connotations, but is introduced as a way of expressing a part of the person (The over-controller coping mode) often with good intention that fulfils multiple functions to avoid broad EMSs activation and serves as a survival strategy. Recently, Loose et al. (2020) have developed a frame in their book which combines schema therapy with family therapy assumptions and techniques. They elaborate on schema therapy parent coaching which extends the skills of the parents to focus on their own basic needs, schemas and modes as well as their child's. In this newly introduced model, the therapist assists parents to see their children through the lens of schema modes and to build creative ways of handling parent-child interaction. To our best of knowledge, to date, there has been no evidence-based study with the focus on the combination of ST and Family Therapy assumptions particularly for ED population. In our current study, we are going to test the feasibility of an alternative treatment model that combines Schema Therapy mode model and family therapy assumptions and techniques. This program will be parent-focused and will be presented in a group format which provides caregivers with an opportunity to openly express and address difficult thoughts and feelings. We hypothesize that Parent-Focused Group Schema Therapy Program will minimize the risk of the likely interpersonal conflict that will ensue in FBT, considering the fact that EMSs of the adolescent AN, parents' EMSs, attachment issues and mode activations have not been addressed in the FBT model. Also, given the lack of clear consensus on effective treatment models for adolescent AN in Iran and the lack of official treatment centers to provide family interventions, the current mixed method study which is a pilot research, intends to contribute to the design and implementation of a deeper level intervention for families of anorexic adolescents and aims to see to what extend this newly introduced intervention will be feasible and acceptable for adolescents' AN symptoms reduction, and improvements in parents emotion regulation skills, parent-child interaction and family quality of life. |
