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Keywords:

  • Compassion-focused therapy;
  • eating disorders;
  • eating disorder treatment

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. Part 1: The problems CFT-E was designed to address
  5. Part 2: Addressing eating disorder problems with CFT-E
  6. Part 3: Outcome and developments
  7. Conclusion
  8. References

Objectives

This article outlines specific developments in compassion-focused therapy (CFT) for the treatment of patients with an eating disorder.

Methods

The article provides a narrative review based on the existing literature and current practices of CFT for eating disorders (CFT-E).

Results

The role of shame, self-criticism, self-directed hostility, and difficulties in generating and experiencing affiliative emotion in patients with an eating disorder is highlighted. The article describes how CFT-E uniquely addresses these issues and discusses the current evidence base for CFT-E. It also provides an outline of recent and potential future developments in CFT-E.

Conclusions

CFT-E offers a promising treatment for adult outpatients who present to specialist eating disorder services with restricting and binge/purging eating disorders. Recent developments include treatment protocols for patients who are low weight and have an eating disorder and for those presenting with obesity.

Practitioner points

  • CFT-E is a group-based treatment for adult outpatients with restricting or binge/purging eating disorders attending specialist services.
  • CFT-E has a specific protocol and interventions to address the biological, psychological, and social challenges of recovery from an eating disorder.
  • CFT-E specifically addresses the high levels of shame and self-criticism commonly experienced by patients with an eating disorder.

Background

  1. Top of page
  2. Abstract
  3. Background
  4. Part 1: The problems CFT-E was designed to address
  5. Part 2: Addressing eating disorder problems with CFT-E
  6. Part 3: Outcome and developments
  7. Conclusion
  8. References

Compassion-focused therapy (CFT) was specifically developed to address shame, self-criticism, and self-directed hostility by helping people to cultivate affiliative emotions and compassion (Gilbert, 2000, 2009, 2010; Gilbert & Irons, 2005). These are seen as important trans-diagnostic problems for people with mental health difficulties (Gilbert, 2014), including people with eating disorders (Allan & Goss, 2011; Goss & Allan, 2009; Goss & Gilbert, 2002). They have been identified as potential aetiological, maintenance, and relapse risk factors in a range of psychological problems and make it difficult for people to seek and use support.

There is evidence that helping people develop compassion for themselves and others can significantly alleviate a range of mental health problems (Hoffmann, Grossman, & Hinton, 2011). CFT has been found to reduce depression and anxiety in people presenting to a community mental health team (Judge, Cleghorn, McEwan, & Gilbert, 2012), patients with long-term mental health problems (Gilbert & Proctor, 2006), and those in a high security psychiatric setting (Laithwaite et al., 2009). CFT has also been shown to be effective for people with psychosis (Braehler, Harper, & Gilbert, 2013; Braehler, Gumley, et al., 2013; Mayhew & Gilbert, 2008) and can significantly reduce paranoid ideation (Lincoln, Hohenhaus, & Hartmann, 2013). CFT has also demonstrated its effectiveness in people diagnosed with a personality disorder (Lucre & Corten, 2013). Ashworth, Gracey, and Gilbert (2011) found CFT to be a valuable addition to the treatment of people with an acquired brain injury. Therefore, there is a growing evidence base for CFT that supports the value of helping people to develop affiliative and prosocial emotions and competencies (including developing compassion for the self and other) to help improve mental health.

Part 1 of this article discusses the role of shame, self-criticism, self-directed hostility, and compassion for self and others in patients with an eating disorder. It then describes the development of CFT for eating disorders (CFT-E) to address these issues. Part 2 describes how CFT-E is applied to the specific challenges of recovering from an eating disorder. Part 3 reviews the current evidence base for CFT-E and highlights some recent and potential developments followed by a concluding section.

Part 1: The problems CFT-E was designed to address

  1. Top of page
  2. Abstract
  3. Background
  4. Part 1: The problems CFT-E was designed to address
  5. Part 2: Addressing eating disorder problems with CFT-E
  6. Part 3: Outcome and developments
  7. Conclusion
  8. References

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:

  1. 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.
  2. The drive, vitality, and achievement system: This is associated with emotions of pleasure and excitement and behaviours of approach and engagement.
  3. 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.

Part 2: Addressing eating disorder problems with CFT-E

  1. Top of page
  2. Abstract
  3. Background
  4. Part 1: The problems CFT-E was designed to address
  5. Part 2: Addressing eating disorder problems with CFT-E
  6. Part 3: Outcome and developments
  7. Conclusion
  8. References

CFT-E required further development from standard CFT to help patients manage the challenges of recovery from their eating disorder. Therefore, in addition to addressing shame, self-criticism, developing the capacity to offer and receive compassion from others, and to be more self-compassionate, CFT-E also focuses on the following:

  1. Developing an eating disorder functional analysis.
  2. Working with eating disorder beliefs and behaviours associated with the threat, drive, and soothing systems.
  3. Managing the biological challenges of recovery.
  4. Managing the social consequences of recovery.
  5. Living in a dieting culture.

CFT-E has a three-stage treatment process: psycho-education, capacity building, and recovery. Patients with an eating disorder, in common with other patients experiencing high levels of shame and self-criticism, tend to be socially isolated, or find it difficult to access or use social support (Norman, Herzog, & Chauncey, 1986). To address this CFT-E is delivered in a group format and provides out-of-session individual telephone support.

CFT-E takes an incremental approach to the experience of working in a group. The psycho-education phase uses a didactic/individual learning approach, where patients are not required to provide personally exposing information. Later, during the capacity-building and recovery phases of treatment, the group is used to develop a shared purpose for recovery and to practise giving and receiving compassion. This helps patients to directly address ‘fears of compassion’ within the group, and assists with the social isolation and feelings of shame shared by many patients with an eating disorder. The aims, content, and structure of these phases are discussed in more detail by Goss and Allan (2010, 2011).

Developing an eating disorder functional analysis

CFT-E has a specific model and philosophy. It proposes that humans have a complex body, which did not evolve to regulate eating but evolved for energy conservation and weight gain in the context of food scarcity. In addition, humans have to manage their complex, evolved affect regulation system. CFT-E sees eating disorders as the persons attempt to manage their body and their affect regulation system in the context of personal and social experiences, which have accentuated threat system processing. For example, patients often experience shame, and other complex blends of emotions, and use eating, weight and shape management to regulate these experiences. This gives rise to certain types of mindsets (e.g., ‘eating disordered’ or ‘food as fun’ mindsets) and safety strategies (e.g., restriction, bingeing and purging) that provide temporary relief and distraction for from difficulties. However, these can also give rise to unintended biological, psychological, and social consequences that leave individuals trapped in vicious cycles.

CFT-E proposes that these mindsets and strategies are not the fault of the individual but are the consequences of their complex evolved brain and body, their personal history, their cultural context, and their current environment. We spend time helping the patient intellectually and emotionally accept this. However, we emphasize that managing these issues are the work of therapy and thus we aim to enable the patient to take personal responsibility for making the changes necessary to recover from their eating disorder and to use therapy and social support to achieve this. One of the key changes is for the patient to eat regularly and sufficiently (normalized eating) and to develop alternative ways of managing the threat, drive, and soothing systems (Goss & Allan, 2010, 2011).

CFT-E can be a challenging model, particularly for patients who believe that their difficulties are their own fault, or are a sign of personal weakness and are very self-attacking. It requires patients to explore the development of their eating disorder mindsets and behaviours and how these may have helped them manage difficult experiences both now and in the past. CFT-E also requires them to change their eating behaviour and this is highly likely to activate their threat system.

The CFT-E model is initially presented during the psycho-education phase, and is elaborated on during the capacity-building phase. In the latter phase, there are opportunities to discuss how mindsets work, identify triggers to eating disordered mindsets, identify and label feelings, and begin work on managing painful memories. The therapist helps and guides the patient to develop their own CFT-E formulation that is then shared with both the therapy team and group. Patients can often slip into a self-critical or self-attacking mindset, therefore collaborative formulation takes place once patients have practised and can maintain a ‘Compassionate Mind’ to some degree. These initial formulations are further developed during the recovery phase and are the basis of recovery work.

Working with eating disorder beliefs and behaviours associated with the threat, drive, and soothing systems

CFT-E is designed to address how the ‘three circles' model of affect regulation appears to be uniquely expressed by patients with an eating disorder. This includes the following:

  1. How the threat system is activated around themes of size, shape, weight, and eating control, and the internal sensory feelings of hunger or fullness.
  2. How the positive emotions associated with the drive system may be associated with issues of weight, shape, and eating control. For example, a sense of pride and achievement by losing weight or resisting hunger.
  3. How the soothing system may be activated by particular foods and/or by the experience of eating.
The threat system

The core difficulties for people with an eating disorder are negative emotions and cognitions about weight and shape; fear of weight gain or being at a specific weight; self-worth being assessed almost exclusively in terms of shape and weight; and body image disturbances impacting on psycho-social functioning (Fairburn & Cooper, 1989; Fairburn, Cooper, & Shafran, 2003; Fairburn et al., 2009; Garner & Garfinkel, 1982; Waller, 1993). These core difficulties, and the mindsets and behaviours associated with them, are introduced to patients during the psycho-education phase. More specific links between these mindsets and the threat system are explored during the capacity-building phase, when patients develop skills in mindset recognition to help inform their CFT-E formulations.

During the recovery phase patients explore compassionate ways of managing both their eating disordered and their self-critical mindsets. This involves using distraction, developing affect tolerance, practising self-soothing, and being open to receiving compassion from others. They also practise self-compassion skills including compassionate imagery (imagining kindness, encouragement, and support from another), Compassionate Letter writing and Compassionate Thought Balancing (Goss, 2011). Patients are also taught how to set up and engage in behavioural experiments and to manage their fear and disgust responses via graded exposure.

In this population we also find that many patients struggle with traumatic memories. Such experiences are explored during the development of their personal formulation. They are worked with using imagery re-scripting and by identifying ways in which they can manage these experiences in the present (Goss, 2011). See Lee (2012) for an overview of CFT interventions for trauma.

The drive system and pride

People with an eating disorder often develop a sense of pride based on their eating disordered behaviours. Pride in eating disorders was first recognized by Bruch (1973), who noted that one of her patients experienced ‘a sense of glory and pride in the self-denial and feeling hungry’ (p. 268). Two qualitative studies (Elsworthy, 2006; Skårderud, 2007) have suggested that pride is implicated in the maintenance of eating disorders, particularly restricting eating.

Skårderud (2007) reported that various forms of pride were common themes in the narratives of 13 participants with AN. These included pride in self-control, pride in being extraordinary (e.g., being able to restrict when others cannot), pride in appearance, and also pride in the use of thinness to signal rebellion and protest. These findings were replicated by Elsworthy (2006) with patients with AN and bulimia nervosa (BN).

The relationship between pride and eating disorders is introduced during the psycho-education phase. During the capacity-building and recovery phases patients are supported in developing alternative foci for pride and rebellion. During the recovery phase, patients may begin to grieve for the ways in which the unintended consequences of pride based around their eating disorder may have affected them and others. Indeed, in CFT the ability to grieve for various affiliative losses can be important for the process of change (Gilbert & Irons, 2005). For example, patients may begin to recognize and process just how lonely they have felt locked away in their eating disorder, how unloved or how unlovable they feel and a yearning for validation, acceptance, and connectedness can emerge.

The soothing system

Goss (2011) proposed that the soothing system and eating are closely linked as being fed and eating are usually experienced as comforting by humans. For most of human history food was scarce, often low in energy and required a significant amount of effort to obtain. Hence, humans evolved a ‘see food and eat it’ approach and are particularly attracted to energy dense and sweet foods. Humans evolved relatively few mechanisms for self-restraint around eating as they were not needed. Instead, we are predisposed to overeat and gain weight to manage famine. In addition, hunting and farming involves high levels of social cooperation and humans affiliate with each other by sharing food. This is linked to feeling cared for or caring for others and hence is associated with the soothing system. Goss (2011) argued that these evolved responses to food and eating may be become problematic if they are the only ways in which a patient can access the soothing system, particularly if they are concerned about weight gain.

Patients are introduced to the role that food and eating play in the normal regulation of emotions during the psycho-education phase and explore their personal experiences during the capacity-building and recovery phases of the programme. This is aimed at helping them to develop compassion for their eating and how it can become closely linked with their emotions.

A further aim is to generate alternative ways of thinking and feeling about the self rather than with self-criticism and shame that may be associated with the body's normal need for food or with the use of food as a soothing strategy. Patients work on alternative ways to activate their soothing system and develop their ability to discriminate between hunger and eating for comfort. As patients recover from their eating disorder they are encouraged to practise eating socially and to enjoy ‘comfort foods’.

Managing the biological challenges of recovery

CFT-E proposes that there are a number of challenges related to the biological changes that patients will experience during recovery. This is based on the set-point theory of weight regulation and includes the following:

  1. Understanding and accepting the body's need for nutrition, activity and rest.
  2. Understanding and managing the impacts of biological starvation.
  3. Eating regularly.
  4. Eating enough.
  5. Managing the biological changes that are a consequence of regular and sufficient eating.

People with binge/purging or restricting eating disorders deliberately override their need for food. This frequently leads to biological starvation as their body consistently consumes less energy than it needs. Biological starvation leads to a range of difficulties. These include preoccupation with food and eating; episodes of overeating, depressed mood, and irritability; obsessional symptoms: impaired concentration: reduced outside interests; loss of sexual appetite; social withdrawal and relationship difficulties (Keys, Broze, & Henschel, 1950).

Like other treatments, such as CBT, CFT-E addresses biological starvation as a necessary (but not sufficient) first step to recovery. Therefore, developing ‘normalized eating’ is an early and important goal of the recovery phase. This involves restoring regular eating patterns, eating sufficient food to meet the body's energy needs, and attaining a healthy body weight.

Patients are introduced to set-point theory at the psycho-education phase. One aim of recovery is for compassionate acceptance of the body's need for food, activity and rest, and accepting one's set-point weight and shape. This can be very upsetting for patients who may have spent many years trying to change their set point. Patients are encouraged to explore their feelings about set-point theory using homework activities during the psycho-education phase, during their post psycho-education review, and during the recovery phase.

Patients are introduced to the principles of ‘normalized’ eating during the psycho-education phase. A presentation using real food takes place during the capacity-building phase which provides an example of a regular eating pattern and an average amount of food to be eaten in a day. Patients are encouraged to explore the anxieties they may have about changing their eating during their individual review at the end of the capacity-building phase. They then develop a personal meal plan in their individual dietetic review before they begin the recovery phase.

The early focus in the recovery phase is to manage a meal plan and to address the impact this has on their threat, drive, and soothing systems. It is likely that changing eating will activate threats related to size and weight change. Therefore patients are weighed prior to the start of each recovery group. Blocks to meal planning include; the biological side effects of starting to eat regularly (such as bloating and urges to exercise); concerns about weight and shape; fear of losing control of weight, eating or emotions; and the loss of pride that was previously gained from their eating disordered behaviours. A main aim of the recovery phase is to help patients develop compassion for these experiences. Additional aims include helping patients manage feelings of shame and self-criticism that can be associated with the avoidance of treatment tasks, the difficulties managing the challenges of recovery, and feelings of grief for the years spent trying to fight their body's needs.

The patient's motivation to change frequently wavers at this point. Once again compassionate validation, normalizing de-shaming, support and encouragement are important here. Group members can be especially important and helpful. The psycho-education phase specifically explores the unintended consequences of having an eating disorder and positive reasons for change using a motivational interviewing approach. The capacity-building phase aims to further enhance motivation. It does this via explicit discussion of the patient's aims for recovery and the development of ways to remind themselves of why they wish to recover. In the recovery phase, patients use their ‘Compassionate Mind’ and draw on the ‘Compassionate Mind’ of the group and therapy team to understand and manage their fluctuations in motivation.

Later in the recovery phase the focus shifts to addressing eating disordered behaviours working on a ‘hierarchy of harm’ approach, starting from life ending through to life limiting behaviours. Of course patients may need to address a number of levels of the hierarchy in one go, or may need to move down several steps if their behaviours become more risky. This hierarchy initially addresses behaviours which pose a risk to self-harm or harm to others prior to beginning group treatment. In the early stages of recovery patients work on establishing regular and sufficient eating. Once regular eating and a healthier energy balance are established, behaviours likely to have detrimental physical effects become the focus for recovery. These include bingeing, laxative abuse, vomiting, drugs used for weight loss, and overactivity. As these improve, factors that are likely to maintain or trigger eating disordered behaviours are addressed. These may include non-supervised weighing, mirror and body checking, and negative social comparisons. ‘life-limiting’ behaviours are addressed next. These include eating socially, eating ‘feared’ or ‘comfort’ foods, and entering situations where one's body may be seen by others. The final stage of this work is developing body acceptance and body appreciation, recognizing feelings of hunger and fullness, moving from meal planning to intuitive eating and enjoying eating.

Managing the social consequences of recovery

For some patients recovery will involve physically obvious changes in their size and shape. For others changes may be more subtle such as eating more often, eating with others, and becoming more assertive, sociable and confident. These changes are likely to lead to reactions from the patient's social network. These may include positive comments about the patient's new size or improved health. They may also be encouraged to eat more than they feel safe with, or to eat socially before they are ready. For some patients their increased assertiveness or happiness may exacerbate relationship difficulties, or they may even experience direct negative comments about their eating or weight.

The possible reactions of other people are explored as potential obstacles to recovery during the psycho-education phase and can be a focus of group work during the recovery phase. Here the aim is to help patients discriminate between the well intentioned comments and behaviours of others that may accidentally trigger their threat system and other more deliberate acts of criticism and bullying. During the recovery phase group members often offer mutual support and encouragement in managing such potentially harmful interactions. They may explore ways to be compassionate to those who want to help and find ways for friends and relatives to express their support and encouragement.

Living in a dieting culture

One of the major challenges facing patients recovering from an eating disorder is managing the complex social messages of a culture that is both preoccupied with dieting and at the same time encouraging high levels of food consumption. The psycho-education phase highlights these mixed messages, discusses the high failure rate and the side effects of dieting, and explores the impact of the powerful cultural messages about size, shape, and weight for people trying to recover from an eating disorder. CFT-E promotes an alternative to these widespread cultural messages. It aims to help patients distance themselves from social pressures and judgements about their size, shape, and eating, and emphasizes the compassionate acceptance of one's body and its needs.

Part 3: Outcome and developments

  1. Top of page
  2. Abstract
  3. Background
  4. Part 1: The problems CFT-E was designed to address
  5. Part 2: Addressing eating disorder problems with CFT-E
  6. Part 3: Outcome and developments
  7. Conclusion
  8. References

CFT-E outcomes

Preliminary evidence for the effectiveness of introducing CFT into a standard CBT programme has been encouraging. Gale, Gilbert, Read, and Goss (2012) reported on a retrospective analysis of routinely collected audit data. This indicated significant improvements on a wide range of self-reported eating disorder symptoms over the course of the treatment programme. Those diagnosed with BN benefited most, with three-quarters considered ‘recovered’ (in terms of making clinically reliable and significant improvements) by the end of treatment. Patients diagnosed with eating disorders not otherwise specified appeared to benefit from the programme, with their recovery rates somewhat lower than those experienced by BN patients, but higher than for those with AN. Those diagnosed with AN benefited least. Nonetheless, a third of those diagnosed with AN were considered ‘recovered’ and an additional quarter were in the nonclinical range by the end of treatment. The relatively poorer outcomes reported for patients with AN compared to BN need to be considered in the context of a lack of evidence for any other effective group treatment for AN (Leung, Waller, & Thomas, 1999).

A study by Holtom-Viesel, Allan, and Goss (2014) has investigated the impact of the CFT-E on self-compassion, self-criticism and shame over the course of a particular version of the treatment programme. In this version of the programme the CFT component was only introduced once a general psycho-educational component and a CBT component had been completed. When the two earlier treatment components had ended it was found that levels of shame and self-criticism had significantly increased. It was only when the CFT component was introduced that levels of self-compassion increased and levels of self-criticism and shame significantly reduced. In addition, it was only once the CFT component had been introduced that the levels of self-reported eating disorder symptoms started to reduce. There are a number of limitations with this research and further research on treatment outcome is required. However, it seems clear that the introduction of the CFT component had not been harmful and was well received and valued. This suggests CFT-E has a potentially significant role in improving the outcome of treatment for people with eating disorders.

Recent developments in CFT-E

Patients with an eating disorder who are low weight

Modification and adaptations of the standard CFT-E treatment programme are currently being developed for patients with low weight eating disorders. The Gale et al. (2012) study noted that the (relatively) poorer outcomes for those with AN, compared to those with BN, in CFT-E might be linked to the comparatively small change in self-directed hostility that AN patients reported at the end of treatment. Tierney and Fox (2010) have also highlighted that people with AN have a particularly strong internal critical voice that is experienced as both a powerful and a necessary part of the self. Thus an extended (40-week) group-based CFT-E for those with low weight (BMI 14.5–17.5) has recently been developed to allow more time to be spent developing compassionate mind skills and addressing key anxieties about becoming less self-critical. The first CFT-E group for low weight patients is currently being evaluated. Results thus far appear promising and the treatment was acceptable to patients.

Patients with obesity

Adult patients seeking treatment for obesity share many beliefs and behaviours in common with adult patients seeking treatment for an eating disorder, including high levels of self-criticism and shame (Franks, 2011). Modifications to the CFT-E programme have also been developed for adult patients seeking treatment for obesity and a self-help book has also been published (Goss, 2011). A study is currently underway to determine whether there are advantages to offering practitioner guided self-help using this book in addition to treatment as usual by a dietetic service for weight management. A further study is planned to investigate the possible advantages of group-based CFT-E for those seeking treatment for obesity.

Conclusion

  1. Top of page
  2. Abstract
  3. Background
  4. Part 1: The problems CFT-E was designed to address
  5. Part 2: Addressing eating disorder problems with CFT-E
  6. Part 3: Outcome and developments
  7. Conclusion
  8. References

CFT-E builds on other evidence-based interventions and is specifically developed to address the biological, psychological, and social challenges of recovering from an eating disorder. In particular it aims to address shame and self-criticism and to assist patients in developing greater self-compassion. Moreover, it is rooted in a neurophysiological, evolutionary, and social contextual model of emotion regulation and self-construction rather than a cognitive one. It explicitly suggests that individuals who struggle to access affiliative processing systems will also struggle to regulate threats and will get caught in ‘drive-threat loops’.

In CFT-E, the core components of CFT are integrated with evidence-based interventions in eating disorders. Throughout patients are taught how to treat themselves and others with wisdom, validation, support, and kindness (in contrast to disappointment and hostility).

CFT-E in its current format offers a promising treatment for adult outpatients who present to specialist eating disorder services with restricting and binge/purging eating disorders. Recent developments in CFT-E have included treatment protocols for patients with low weight eating disorders and for those presenting for treatment for obesity. Future developments include evaluating these new protocols, exploring whether CFT-E can be delivered in an individual format, and whether it can be delivered by nonspecialist eating disorder services.

References

  1. Top of page
  2. Abstract
  3. Background
  4. Part 1: The problems CFT-E was designed to address
  5. Part 2: Addressing eating disorder problems with CFT-E
  6. Part 3: Outcome and developments
  7. Conclusion
  8. References
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