Currently, the best standard therapy for people with eating disorders, Cognitive Behaviour Therapy (CBT), achieves clinically significant improvements in about 50% of patients (Wilson, 1996). In a recent trial of two variations of CBT, 52.7% of people with bulimia nervosa, and 53.3% of those with atypical eating disorders, had clinically significant improvements (Fairburn et al., 2009). Clearly, a number of people still struggle with this disorder despite such interventions, indicating a need for improvements in psychological therapies (NICE, 2004, 2011). Improvements come with greater understanding of the processes involved in the disorder, functional analysis, and targeting therapies at those processes (Gilbert, 2007). People with eating disorders tend to be highly self-critical (Lehman & Rodin, 1989; Speranza et al., 2003) and shame-prone (Goss & Gilbert, 2002; Swan & Andrews, 2003), and these are linked to relatively poor outcomes, even in people who appear to gain symptomatic control during eating disorder treatment (Troop, Allan, Serpell, & Treasure, 2008). Self-criticism is also an independent, robust, and strong predictor of eating disorder symptoms (Fennig et al., 2008) and can interfere with therapy (Bulmash, Harkness, Stewart, & Bagby, 2009).
Compassion Focused Therapy (CFT) was specifically designed for people with high shame and self-criticism (Gilbert, 2000, 2009, 2010). People with these difficulties often experience high levels of external threat (fear of criticism and rejection) and internal threat (self-criticism and feelings associated with being a failure, flawed and inferior). Shame can have different forms and be associated with a range of different backgrounds including abusive, neglectful, competitive and physically nonaffectionate (Gilbert, 1998, 2002, 2009). Peer bullying (Gibb, Abramson, & Alloy, 2004) and sibling rivalry (Gilbert & Gerlsma, 1999) can also overly focus children and adolescents on feelings of inferiority and inadequacy, from which shame and self-criticism can arise. There tends to be a high incidence of childhood abuse and violence in people with eating disorders (Schmidt, Tiller, & Treasure, 1993) and high levels of pre-morbid negative self-evaluation and self-criticism (Fairburn, Cooper, Doll, & Welch, 1999; Fairburn, Welch, Doll, & Davies, 1997). A central feature for people from these backgrounds, and with high shame and self-criticism, is that they can find it very difficult to be self-reassuring or self-compassionate and be fearful of affiliative emotions (Gilbert, McEwan, Matos, & Rivis, 2011). CFT focuses on the development of affiliative emotions towards the self and others.
There is increasing evidence for the effectiveness of CFT with a range of different mental health problems. In an early study of CFT with a group of people with chronic mental health problems attending a day hospital, Gilbert and Procter (2006) found that CFT reduced self-criticism, shame, depression and anxiety. Subsequent studies have found significant improvements using CFT for people with psychotic and complex disorders (Braehler, Gumley, Harper, Wallace, & Gilbert, ; Laithwaite et al., 2009), personality disorders (Lucre & Corten, ) and people presenting to a community mental health team (Stewart & Holland, 2011). Recently, Beaumont, Galpin and Jenkins (2012) compared CBT against CBT plus CFT in clients who had experienced trauma and found a nonsignificant trend for greater improvement in the CBT plus CFT group. Additionally, the CBT plus CFT produced significantly greater increases in self-compassion. As a result, Beaumont and colleagues (2012) suggest that developing self-compassion could be an important adjunct to therapy. Similarly, Ashworth, Gracey and Gilbert (2011) found CFT to be helpful in reducing shame and self-criticism for people with acquired brain injury. The authors again suggest that adding CFT to established interventions may make them more effective.
To date, however, there has been no study of CFT within an eating disorder setting. The Coventry Eating Disorders Service is the first service to introduce CFT into the treatment of eating disorders and has done so since 2002 (Goss & Allan, 2010). To maximize clinical efficiency, the service provides group-based treatments with a two-step treatment programme. In step one, patients are offered a 4-week, 2 hours per week, group-based psycho-education programme. Participants take part in the four psycho-education sessions, which are outlined in Table 1. The programme is mainly didactic teaching, with in-session written activities and homework. It is designed to help patients increase their understanding of their eating disorder and be actively involved in deciding if they are ready to engage in treatment.
Table 1. Overview of the psycho-education programme (Step one)
|Session one: ‘the facts’||What is an eating disorder?|
|• Diagnoses and definitions|
|• Similarities across the disorders|
|How did I get into this?|
|• Listening to other peoples stories|
| ||• A model for understanding disorders|
|Session two: ‘why can't I stop?’||Psychological and social factors that can maintain an eating disorder:|
|• Eating disorder as a solution to problems|
|• Eating disorder as a trap|
|Biological factors that can maintain an eating disorder:|
|• What is a healthy body weight|
|• Calculating a healthy body weight|
|• Set point theory of weight regulation|
|• Over-riding the hunger-satiety system|
|Eating disorder patterns:|
|• Energy needs|
|• Excessive exercise|
| ||Thoughts, feelings, memories|
|Session three: ‘the risks involved when having an eating disorder’||• Physical risks of starvation and of bulimia|
|• Psychological costs (mood, rules, overgeneralization, sleep and concentration)|
|• Social costs (avoiding social situations, too tired/too ill to go out, social anxiety, financial implications and impact on others)|
| ||• Occupational costs (impact of symptoms, career choice and career limitation)|
|Session four: ‘what will recovery involve?’||What is recovery? |
• Biological recovery (importance of normalizing eating, what is normal eating, what stops normal eating, mechanical eating and meal planning, what makes up body weight, normal body weight changes and body weight changes in recovery)
|• Psychological recovery (coping with the distress caused by normalizing eating and weight, preventing relapses and dealing with vulnerability factors)|
|• Expectations of therapy (personal responsibility for change, therapist responsibility, patient responsibility and treatment types and their effectiveness)|
|• The process and stages of change|
|• Getting the conditions for change right (solving practical problems and getting support)|
An audit of the psycho-education programme indicated little significant symptom change (Moffat, 2006). However, patients reported finding it a helpful first step in introducing them to working within a group and deciding whether or not to opt in for treatment, and there was a significant increase in overall motivation to change.
Step two of the treatment programme is a 20-session group-based recovery programme. This takes place over 16 weeks, with two sessions a week for the first 4 weeks, followed by weekly sessions over 12 weeks. There is limited telephone or face-to face support between groups. Each group lasts between 2 and 2.5 hours, with 2 hours of homework tasks each week.
The original recovery programme was based on the principles of CBT for eating disorders (Fairburn, 1981). However, it was observed that many individuals struggled to experience emotional change, particularly in relation to feelings of shame and self-criticism. To address this, the head of the service (KG) and his team began introducing CFT in 2002. Table 2 gives an overview of the elements of CBT and CFT included in the programme. All members of the team facilitating the recovery programme have received formal training and/or supervised practice in both CBT and CFT. The areas covered by each session of the recovery programme are outlined in Table 3. The stages of the programme, and the number of people attending each stage between April 2002 and October 2009, are outlined in Figure 1.
Table 2. Composition of the Recovery Programme (Step two)
|Cognitive Behavioural Therapy (Fairburn, 1981)||• Identification of core beliefs, maintaining behaviours and physical states|
|• Meal planning|
|• Cognitive challenges|
|• Behavioural experiments|
| ||• Problem solving|
|Compassion Focused Therapy (Gilbert & Procter, 2006; Gilbert, 2010)||• Evolutionary functional analysis|
|• Understanding symptoms (e.g., restricting or bingeing) as related to safety and emotion regulation strategies|
|• Understanding the origins and functions of self-criticism, shame and pride|
|• Focus on development of affiliative motivation and emotion directed at self and others|
|• Working on the fears and blocks to developing compassion|
|• Developing compassionate focusing using a variety of interventions, including compassionate imagery, thinking, behaviour or emotion|
Table 3. Overview of the recovery programme (Step two)
|Week||Session||Topic area/aim of the session|
|Week 1||Session 1||• Validation and encouragement for attending|
| ||• Developing group purpose and cohesion|
|Session 2||• Continuing to develop group purpose and cohesion|
| || ||• Introducing the CBT model and self-monitoring|
|Week 2||Session 3||• Elaborating on the CBT model and self-monitoring|
|Session 4||• Review and manage self-monitoring blocks|
| || ||• De-shaming discussion of eating disorder thoughts and behaviours|
|Week 3||Session 5||• Identification of eating disorder risks|
|• Introduce using the group to support problem solving|
|• Focus on coping|
| ||• Introduce principles of normalized eating and meal planning|
| ||Session 6||• Continue to work on self-monitoring, meal planning, and predicting and managing blocks to meal planning|
|Week 4||Session 7||• Review problems and solutions to meal planning|
|• Introducing CFT and the underpinning theories|
|• Explore the basic concepts of compassion and what compassion entails|
| ||• Introduce compassionate interventions imagery (e.g., safe place and compassionate other imagery)|
|Session 8||• Review understanding of CFT and meal planning|
|• Understand how compassion can be used to engage with difficulties|
|• Introduce distress tolerance skills|
|• Introduce weighing|
| || ||• Prepare for individual review|
|Weeks 5–10||Sessions 9–14||• Manage being weighed, and identify and manage worries about weight and weighing|
|• Develop and work on list of weight/shape related worries|
|• Agree and work on individual recovery targets|
|• Gradually increase planned energy intake up to minimum of 1500 calories|
| || ||• All of this is undertaken with a compassionate focus, using compassionate imagery (including imagining the self as compassionate), and a focus on developing compassionate thinking and behaviours.|
|Weeks 11–15||Sessions 15–19||• As previous sessions and increase planned energy intake up to minimum of 2000 calories|
|• Introducing feared foods|
|• Relapse prevention and planning for a life without an eating disorder|
| || ||These interventions are undertaken with a compassionate focus, using compassionate imagery, and developing compassionate thinking and behaviours.|
|Week 16||Session 20||• Exploring relapse prevention and goodbyes; again, this is done with a compassionate focus.|
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This study aimed to evaluate the outcome of introducing CFT into a standard CBT programme for people with eating disorders, with a view to proving the principle that CFT can be used with people with eating disorders. The results of the evaluation support this principle. The main findings are that there are significant improvements on all of the EDE-Q, SEDS and CORE-OM subscales during the treatment programme. The data suggest that introducing CFT does not worsen outcomes. In addition, although only anecdotal evidence, the clinicians reported that patients understood the model and could see the value of it, even those who may not have improved as much as the other participants.
When broken down by diagnosis, it is the people with bulimia nervosa (and EDNOS to some degree) who seem to particularly benefit from the programme. Although those with anorexia nervosa show more modest changes, 33% of people with anorexia nervosa were considered ‘recovered’ (i.e., made clinically reliable and significant improvements during the programme) or ‘improved’ (i.e., made clinically significant improvements) at the end of treatment, and a further 26% scoring within the ‘functional’ range on the EDE-Q (but the change was not statistically reliable). In a population for which there is very limited evidence for any effective treatment, particularly in groups (Leung, Waller, & Thomas, 1999), this is a promising result. Thus, this evaluation offers encouraging evidence that a CFT programme can be used with people with bulimia nervosa, anorexia nervosa and EDNOS.
Interestingly, given the focus of CFT, there was only a small change in self-directed hostility in the anorexia nervosa group. A much larger improvement was noted in the bulimia and EDNOS groups (Table 4). A study looking at the critical voice of people with anorexia nervosa found that participants felt they were dependent on the voice, believing that they were unable to function without it, and they experienced a sense of loss when they started to fight back against the voice (Tierney & Fox, 2010). This suggests that the attachment to the critical ‘voice’ is particularly strong for people with anorexia nervosa and that therapists need to be sensitive to this when working with them. In addition, a number of recent studies have shown that some people with high self-criticism show aversive responses to compassion, at least to begin with, and these need to be worked through in therapy (Gilbert et al., 2011; Longe et al., 2010; Rockliff, Gilbert, McEwan, Lightman, & Glover, 2008). On the basis of these results, and anecdotal reports from patients and clinicians, more time is now being spent working with the fear of, and blocks to, compassion with the hope that self-criticism will be further improved.
As CFT aims to reduce self-criticism and shame, and to increase self-compassion, further questionnaire measures have recently been introduced to the programme to specifically assess these areas; these are given at the same time points as the other measures. A recent evaluation exploring the impact of the programme on these measures found a significant reduction in internal shame, external shame and self-criticism, and an increase in self-compassion (Holtom-Viesel, 2010). These results support the findings of the current study, which suggest that using CFT, which specifically targets self-criticism, shame and self-compassion, impacts on the symptoms and psychopathology of eating disorders.
The results of this evaluation are comparable with other evaluations of eating disorders services. For instance, the Oxford Adult Eating Disorder Service, which reports on a combination of CBT-based, day and out-patient treatments (Peake, Limbert, & Whitehead, 2005). However, neither standard deviations nor effect sizes are included in the Oxford paper, making statistical comparisons difficult. Also, the evaluation of the Oxford service includes both inpatients and outpatients, further exacerbating the difficulties in drawing any clear comparisons between the two services.
As is common when using routinely collected data, large numbers can be referred to the service, but there are many avenues to disengage or to be referred to other services along the way. In addition, as this is routine clinical data that were not supported by any research assistant but were reliant on clinicians and volunteers, there were many incidences of missing data. This was counteracted where possible by using mean scores for scales if one or two items were missing. However, for those who had a whole set of scales, missing their data could not be included, hence the reduction from 139 people who completed the programme to 99 people with data at the beginning and the end of the programme. However, despite the missing data, the sample size was comparatively large for an evaluation study. Whereas the evaluation of the eating disorder service in Oxford included 110 patients (Peake et al., 2005), other published evaluation studies have included between 44 and 65 patients (Gerlinghoff, Backmund, & Franzen, 1998; Piran, Langdon, Kaplan, & Garfinkel, 1989; Willinge, Touyz, & Thornton, 2010). Data issues also led to difficulties in undertaking longer term follow-up, with limited outcome data for 6 months and beyond. Given the small numbers, these outcomes are not reported on.
Another limitation of this evaluation is in discriminating between the CBT and CFT aspects of the programme. The introduction of CFT has been gradual, and the programme is more compassionately focused now than it was when it was first introduced. This makes it difficult to determine which aspects of the programme led to the improvements or, indeed, if it was a combination of the two. As for all therapies, CFT needs to be evaluated as part of a randomized controlled trial compared with CBT.
These data provide the basis for further research to better evaluate CFT in its own right. There are many research avenues for this development. First would be to obtain qualitative data about the actual experience of patients experiencing CFT as patient experience is a key element of therapy development (NICE, 2004). Qualitative data from people with depression suggest that they recognize the value of compassion and of trying to become more self-compassionate but also articulate a number of difficulties in being able to do so (Pauley & McPherson, 2010).
Second, research must also look at the objective measures of change and the degree to which CFT offers advantage on efficacy, as part of a randomized controlled trial. It is not just scores at the end of treatment that are important but also whether or not, by engaging with compassion processes, this has an impact on relapse rates. Thus, follow-up data are essential for future research. Certainly, CFT would argue that if you create a more affiliative orientation to self and others, this could reduce vulnerability.
Third, increasingly research in psychotherapy is recognizing that it is not only symptom reduction that needs to be the focus for research but also aspects such as quality of life and social functioning. Again, because CFT focuses on affiliative development, it would be anticipated that it would have an impact on quality of life and social functioning.
This study aimed to explore the principle that CFT can be used with people with eating disorders. Clearly, this is just a first step to exploring the value of developing a compassion focused approach for the difficulties people experience within their eating disorders. However, the results of this study are encouraging. Clinicians report that patients understood the model and its value, even if they struggled to implement it for themselves. The programme significantly reduced symptomatology across a range of measures, particularly for people with bulimia nervosa and EDNOS, and to a lesser extent for people with anorexia nervosa.