Shame, self-criticism, self-directed hostility, and self-other compassion in people with an eating disorder
Shame is a powerful and multifaceted experience (Kim, Thibodeau, & Jorgensen, 2011). CFT distinguishes between internal and external shame. External shame is where one's attention is focused on the mind of the other and coping strategies are organized around the regulation of the social interaction. Internal shame is where one's attention is focused inwards on the self and coping strategies are focused on internal affect regulation (Allan, Gilbert, & Goss, 1994; Gilbert, 1998, 2002, 2007; Goss, Gilbert, & Allan, 1994).
Shame can be textured by different emotions (such as feelings of anxiety, anger, disgust and contempt), behavioural responses (such as behavioural inhibition, submissiveness and/or escape) and specific physiological profiles, especially elevated cortisol (Dickerson & Kemeny, 2004). It often involves social comparison with different foci, for example other peoples physical appearance, behaviours or emotions (Gilbert, 1998, 2002; Power & Dalgleish, 1997).
Early recognition of the possible importance of shame in eating disorders can be found in Bruch's (1973) case description of Karol. She outlined Karol's feelings of being a failure, her desire not to become a ‘horrible person, a nothing’, and her use of self-starvation to avoid this fate. Since then there has been increasing interest in the relationship between shame and eating disorders.
Studies suggest that patients with an eating disorder experience significantly higher levels of shame than other clinical groups (Cook, 1994; Frank, 1991; Masheb, Grilo, & Brondolo, 1999) and that the foci of shame may also be different, being more related to eating (Frank, 1991) and eating disordered behaviours (Sanftner & Crowther, 1998). Other studies have found that state and trait shame are high in women who currently have, or who are in remission from, an eating disorder, even when controlling for levels of depression (Gee & Troop, 2003; Troop, Allan, Serpall, & Treasure, 2008). Regardless of diagnosis, patients with an eating disorder are likely to be highly self-critical (Goss, 2007) and experience high levels of self-directed hostility (Williams et al., 1993, 1994).
Gilbert, Clarke, Kempel, Miles, and Irons (2004) identified two forms of self-criticism; one focused on mistakes and a sense of inadequacy, and the other focused on wanting to hurt the self and experiencing feelings of self-disgust/hate. They also identified two functions of self-criticism; self-improvement and self-harming/self-persecuting. Barrow (2007) found that patients with an eating disorder criticized themselves more for the purposes of self-harming/self-persecution and reported significantly lower levels of self-compassion than a student comparison group. Fennig et al. (2008) found that self-criticism is a strong, independent, and robust predictor of eating disorder symptoms. In a qualitative study, Tierney and Fox (2010) found that people with anorexia nervosa (AN) can be particularly hostile in their self-criticism. More recently, Kelly and Carter (2012) found that shame mediated the relationship between self-criticism and higher levels of eating disorder pathology. For a more detailed review of the relationship between shame and eating disorders see Goss and Allan (2009) and Allan and Goss (2011).
In contrast to shame and self-criticism is the capacity for being open to compassion from others and the self. Kelly, Carter, Zuroff, and Borairi (2013) found that low self-compassion and fear of compassion were associated with higher levels of shame, eating disorder pathology, and poorer responses to treatment. Ferrieira, Pinto-Gouveia, and Duarte (2013) reported that self-compassion was negatively associated with external shame and both general and eating psychopathology in women with an eating disorder.
The development of compassion-focused therapy for eating disorders (CFT-E)
Compassion-focused therapy originally developed as a treatment to target shame, self-criticism, and self-directed hostility. These were seen as processes to be addressed via the development and practice of compassion. This involves three processes: being open to the helpfulness and compassion from others, being helpful and compassionate towards others, and developing an encouraging, supportive, and compassionate approach to oneself (see Gilbert, 2014). These aspects of compassion cultivation can be delivered within individual or group-based therapy (see Gilbert, 2012). CFT is compassion-focused therapy not compassion therapy. This means that standard evidence-based interventions that are helpful for any particular problem is likely to be used by CFT therapists. However, the interventions will be used in conjunction with enabling people to access their affiliative and soothing system. Without this, interventions may be logically understood but people will struggle to experience the interventions as helpful because the emotional system that gives rise to reducing threat is not available.
The initial use of CFT with patients with an eating disorder added some specific CFT practices to the NICE (2005) recommended treatment for eating disorders (cognitive behaviour therapy; CBT) in a group format (Goss & Allan, 2010). It was designed to enhance to the effectiveness of existing treatment approaches by adding interventions to stimulate and cultivate affiliative processing. It includes interventions used in other therapies to help patients manage eating (e.g., meal planning), address changes in weight (such as regular therapeutic weighting), behavioural experiments and exposure, and cognitive restructuring. Over time this developed into a more comprehensive treatment approach with a specific treatment protocol and theoretical model that places compassion cultivation at the heart of the treatment programme. CFT-E proposes that, at least in part, the treatment efficacy of existing therapies for eating disorders is being limited by the patient's inability to use the affiliative soothing system. If skills (such as meal planning), cognitive restructuring or behavioural experiments are not embedded in the affiliative soothing system, at best these are experienced as unhelpful, and at worst can be experienced as threatening.
CFT-E expands upon the original model of CFT to address the biopsychosocial factors that have been identified as having possible aetiological and maintenance roles in eating disorders. These include the biological effects of starvation and chaotic eating, addressing the implications of weight change and set-point theory (Harris, 1990), the function of eating disordered behaviours in regulating threat and drive systems, and the difficulties of living in a culture that is preoccupied with dieting. It pays particular attention to developing the ability to approach and work with one's eating disorder from a compassionate orientation. It uses interventions adapted from CFT to meet the specific challenges of recovery for adult outpatients experiencing restricting and/or bingeing and purging eating disorders.
Having developed out of a CBT group-based eating disorder protocol, CFT-E retains a number of CBT interventions. These include the use of Socratic dialogue, guided discovery, inference chaining, mindful monitoring of thoughts, emotions, and behaviours during sessions, diary keeping, graded exposure to difficult situations, behavioural experiments, problem solving, learning emotional regulation strategies, stress inoculation training, and out-of-session tasks. It also retains elements from CBT protocols specific to eating disorders including structured eating and meal planning, exposure to specific foods and eating situations and a focus on working on issues related to weight and shape.
CFT-E is unique in a number of ways. In particular it emphasis an evolutionary model, which highlights the ways in which the human brain and body have evolved that make the regulation of emotion and the regulation of eating and weight difficult. It also focuses specifically on helping patients foster the ability to experience and use pleasurable emotions as well helping them to manage feelings anxiety, anger, grief, and disgust.
Compassion-focused therapy is derived from an evolutionary and neuroscience model of affect regulation that argues that different affect regulation systems evolved for different functions (Gilbert, 2010; 2014). It focuses on three specific affect regulation systems:
- The threat detection and protection system: This is associated with rapidly activated emotions such as anxiety, anger and disgust, and defensive behaviours of fight/flight/avoidance, and submissiveness.
- The drive, vitality, and achievement system: This is associated with emotions of pleasure and excitement and behaviours of approach and engagement.
- The contentment and affiliative soothing system: This is associated with the experience of peaceful well-being and with giving and receiving affection and affiliation. It allows us to experience social connectedness and soothing from others or from ourselves.
These systems are mutually regulating, and the soothing system is seen as playing a crucial role in affect regulation. As derived from Attachment Theory (Bowlby, 1969), supportive and affiliative others can function as a secure base from which individuals can move forward to explore the external world, the internal world of their own emotions, and act as a safe haven to soothe distress. CFT focuses on balancing affect regulation through the development of affiliative and caring processes (see also Gumley, Braehler, & Macbeth, 2014). It suggests that individuals who are unable to regulate emotion, especially threat-based and shame-based emotions through affiliative processes tend to become over dependent on the drive system (where they need to achieve and do things) or become stuck in threat system responses (Gilbert, 2009, 2010; Gilbert & Irons, 2005).
CFT-E proposes that eating disordered behaviours serve a functional purpose in attempting to regulate threat. First, it suggests that people with eating disorders, especially AN, are highly focused on competitive dynamics where shame and pride (rather than affection or friendship) are the salient self-organizing motives (Goss & Gilbert, 2002). In this (competitive and rank sensitive) social mentality, cooperative and compassionate role formation is either poorly developed or inhibited (see Gilbert, 2014). CFT-E expands on the ‘three-circle’ model of affect regulation (Gilbert, 2009, 2010; Gilbert & Irons, 2005). It suggests that, for patients with an eating disorder, the drive system plays an important role in regulating the threat system via the development of pride in eating disordered behaviours (such as pride in losing weight). It also suggests that a range of strategies (such as trying to fit in with others expectations about size and shape, avoiding triggers to weight related information, or bingeing/purging and self-harm) can be used to regulate the threat system (Goss & Allan, 2009). It argues that, without access to the affiliative system, the drive/pride and threat systems often become interlinked which has many unintended consequences leading to further distress. This can lead to vicious maintenance cycles, which can further preclude or prevent the development of affiliative or self-soothing affect regulation strategies.
The development of CFT-E required a number of modifications and adaptations from standard CFT. These included recognizing the different ways that shame and self-criticism operate in different kinds of eating disorders, developing a greater understanding of the functions that these processes may serve, and targeting the specific biological, psychological, and social challenges that recovery from an eating disorder can involve. This led to the evolution of new functional analytic models for understanding how shame and pride are related in eating disorders and how to help patients develop and use compassion processes to meet the challenges of recovery (Goss & Allan, 2010, 2011).
One of the key aspects of CFT-E is helping patients develop the capacity to manage their threat system. CFT-E focuses on helping patients develop the ability to activate soothing and to develop their affiliative system and to use these to regulate threat and drive. Patients are also taught a variety of affect regulation strategies prior to embarking on behavioural change. CFT-E also emphasizes the use of sensory and imagery practices to stimulate the affiliative system. One of the core practices is the development of the compassionate self, which becomes the focal point for engaging in problematic behaviours and emotions on behalf of oneself and other group members. This can include the use of method acting and psychodrama techniques. This frequently involves working on the fears and blocks to receiving compassion from others and from the self. The key aim is for patients to bring into line and use a compassionate ‘mindset’ to approach all therapeutic tasks. These systems, techniques, and treatment protocols are more fully described below.