A Matched Comparison Study of Group Schema Therapy and Treatment as Usual for Individuals with Disordered Eating and Higher Weight in a Community Setting

Arm 1: Modified Schema Therapy (ST) will be adapted for individuals with eating disorders and higher weight following the group manual set out by Simpson and Smith (2020). Therapy treatment will be groups of 10 participants run by a registered psychologist, and group will focus on the therapeutic alliance, psychoeducation/orientation to schema therapy, assessment and formulation, schema therapy strategies, chairwork, imagery rescripting, and understanding and linking unmet childhood needs to current-day challenges. Therapy sessions will have flexibility while also outlining key components of ST. For example, a session will begin with a review of the previous week (homework, schema/schema mode labelling, food monitor reviewing) and further exploration and elaboration of the various components of early maladaptive schemas (EMS), coping skills, etc. and its relation to disordered eating. Binge-eating will be classified as a self-soothing mode, and severe restriction as a perfectionistic over-controller mode. Homework will take between 30 minutes to 1 hour for participants within the week depending on tasks, and will involve activities such as worksheets (e.g. Schema Mode diary, identifying triggers, coping modes), a genogram outline of their family, mindfulness activities to do within the week, food diaries, etc. Monitoring adherence, depending on the task, will be done through assessing worksheet completion and/or within beginning sessions through reviewing the previous week’s task in group; each session will have an attendance list and associated checkoff for identifying participants who are in attendance. In terms of what sessions may look like, see below an example outline of session 1-4 work: 1. Sessions 1-4 General Themes/Goals a. Explain that the overarching goal is for participants to change behavioural patterns while learning healthy ways of recognising and asking for help. b. Group leaders model a Healthy Adult role, so as participant can gradually take this role on as group proceeds. c. Sessions with focus on understanding the ST model and incorporating ED and other problematic symptoms and behaviours within a mode map conceptualisation. Behavioural goals are linked to ED’s are formulated, linking with their mode map d. Beginning of each session will encourage participants to reflect on how they feel, giving options so that each participant can find a way to expressing their feelings (emotion word lists, facial emojis, emotion cards, emotion wheel) e. Group safety will be cultivated through exercises such as ‘scarves’ activity and group therapy goals are established through psychoeducation of EMS and Modes; a significant amount of time is focused on psychoeducation and exploration of coping modes, and linking these to ED and behaviours f. Measures introduced: i. Schema Mode Eating Diary ii. Schema Mode Tracker iii. Understanding Coping Modes iv. Mode Pie Charts v. Schema Decision Flowchart g. Schema Model i. Everyone has some of these needs met and some unmet, and our job is to do the detective work to figure out the bits that have been positive and that are missing ii. Card games, brick wall exercise iii. Safety, stable base, predictability, love, nurturing, attention, acceptance and praise, empathy, guidance, protection, validation of feelings and needs h. Linking Childhood Needs with EMS i. Metaphors to introduce the concept of EMS: blind spots, emotional buttons, coloured cellophane lenses, coping modes as perpetuating factors i. Exercises i. Mode Mapping group exercise ii. Mode spotting exercise iii. Modes on a bus exercise iv. Mode role plays v. Detective work with pseudo-healthy modes j. Homework with a general theme of behavioural pattern breaking tasks: i. Genogram exercise (participants to identify possible origins of inner critic [parents modes, coping modes, and or schemas in previous generations to then discuss patterns of transgenerational schema/mode transmissions in a group]) ii. Schema Mode Diary Arm 2: Modified 'Healthy APproach to weIght management and Food in Eating Disorders' (HAPIFED) comes from Enhanced - Cognitive Behavioural Therapy (CBT-E) for eating disorders with integrating a program of behavioural weight loss therapy, and education about nutrition and exercise. HAPIFED emphasises eating according to hunger and satiety signals from the body, along with active behaviour change in between sessions. Therapy sessions will be groups of 10 participants run by a registered psychologist, and work in a conjunction between standard CBT-E protocol, nutritional counselling, healthy exercise and behavioural weight loss therapy. HAPIFED has been slightly modified in consultation with those who created the manual. Food dairies will be kept by participants throughout the week, and each session will have an attendance list and associated checkoff to identifying participants who are in attendance and for who completed diaries within group. Treatment interventions will consist of 16 weekly 2-hour group sessions (approximately 4 months) with a single 6-month follow-up.

Allocation will be determined based on scheduling (e.g. availability) ---- Arm 1: Modified Group Schema Therapy (STE-g) will be adapted for individuals with eating disorders and higher weight following the group manual set out by Simpson and Smith (2020). Therapy treatment will be groups of 8 to 10 participants run by one to two clinical psychologists, and group will focus on the therapeutic alliance, psychoeducation/orientation to schema therapy, assessment and formulation, schema therapy strategies, chairwork, imagery rescripting, and understanding and linking unmet childhood needs to current-day challenges. Therapy sessions will have flexibility while also outlining key components of ST. For example, a session will begin with a review of the previous week (homework, schema/schema mode labelling, food monitor reviewing) and further exploration and elaboration of the various components of early maladaptive schemas (EMS), coping skills, etc. and its relation to disordered eating. Binge-eating will be classified as a self-soothing mode. Homework will take between 30 minutes to 1 hour for participants within the week depending on tasks, and will involve activities such as worksheets (e.g. Schema Mode diary, identifying triggers, coping modes), a genogram outline of their family, mindfulness activities to do within the week, food diaries, etc. Monitoring adherence, depending on the task, will be done through assessing worksheet completion and/or within beginning sessions through reviewing the previous week’s task in group; each session will have an attendance list and associated checkoff for identifying participants who are in attendance. In terms of what sessions may look like, see below an example outline of session 1-4 work: 1. Sessions 1-4 General Themes/Goals a. Explain that the overarching goal is for participants to change behavioural patterns while learning healthy ways of recognising and asking for help. b. Group leaders model a Healthy Adult role, so as participant can gradually take this role on as group proceeds. c. Sessions with focus on understanding the ST model and incorporating ED and other problematic symptoms and behaviours within a mode map conceptualisation. Behavioural goals are linked to ED’s are formulated, linking with their mode map d. Beginning of each session will encourage participants to reflect on how they feel, giving options so that each participant can find a way to expressing their feelings (emotion word lists, facial emojis, emotion cards, emotion wheel) e. Group safety will be cultivated through exercises such as ‘scarves’ activity and group therapy goals are established through psychoeducation of EMS and Modes; a significant amount of time is focused on psychoeducation and exploration of coping modes, and linking these to ED and behaviours Data will be collected before randomisation at baseline/pre-treatment, after 16 weeks at post-treatment, and at 6 months follow-up. f. Measures introduced: i. Schema Mode Eating Diary ii. Schema Mode Tracker iii. Understanding Coping Modes iv. Mode Pie Charts v. Schema Decision Flowchart g. Schema Model i. Everyone has some of these needs met and some unmet, and our job is to do the detective work to figure out the bits that have been positive and that are missing ii. Card games, brick wall exercise iii. Safety, stable base, predictability, love, nurturing, attention, acceptance and praise, empathy, guidance, protection, validation of feelings and needs h. Linking Childhood Needs with EMS i. Metaphors to introduce the concept of EMS: blind spots, emotional buttons, coloured cellophane lenses, coping modes as perpetuating factors i. Exercises i. Mode Mapping group exercise ii. Mode spotting exercise iii. Modes on a bus exercise iv. Mode role plays v. Detective work with pseudo-healthy modes j. Homework with a general theme of behavioural pattern breaking tasks: i. Genogram exercise (participants to identify possible origins of inner critic [parents modes, coping modes, and or schemas in previous generations to then discuss patterns of transgenerational schema/mode transmissions in a group]) ii. Schema Mode Diary Treatment intervention will consist of 16 weekly 2-hour group sessions (approximately 4 months) with a single 6-month follow-up.