Compassion Focused Therapy Intervention to Reduce Self-criticism
Main Research Project, Systematic Review & Service Related Project
Contents Page
Main Research Project……………………………………………….Page 3
Systematic Review………………………………………..…………..Page 178
Service Related Project………………………………………………Page 249
Main Research Project
Self-criticism: Development of a new intervention
Contents
Abstract………………………………………………………
1. Introduction………………………………………………….
1.1 Self-criticism……………………………………………….
1.2 The treatment of self-criticism……………………………………
1.3 Constructs related to self-criticism and their treatment……………………
1.3.1 Perfectionism……………………………………………
1.3.2 Self-esteem…………………………………………….
1.3.3 Depressive rumination……………………………………..
1.4 Self-compassion interventions to target self-criticism…………………….
1.5 Student mental health…………………………………………
2. Aims……………………………………………………….
2.1 Hypotheses………………………………………………..
3. Method…………………………………………………….
3.1 Ethical Approval…………………………………………….
3.2 Design……………………………………………………
3.3 Participants………………………………………………..
3.4 Measures…………………………………………………
3.4.1 Primary outcome measures…………………………………..
3.4.2 Secondary outcome measures…………………………………
3.4.3 Process measures…………………………………………
3.4.4 Measures to aid formulation………………………………….
3.4.5 Participant feedback……………………………………….
3.5 Procedure…………………………………………………
3.6 Intervention……………………………………………….
3.7 Feasibility & acceptability objectives………………………………..
3.8 Data preparation and analysis……………………………………
3.8.1 Hypotheses 1 & 2: Feasibility & acceptability……………………….
3.8.2 Hypotheses 3, 4 & 5: Changes in self-criticism and other outcomes…………
3.8.2.1 Therapist effects……………………………………….
3.8.2.2 Effects of waiting for intervention……………………………
3.8.2.3 Comparison between pre and post-intervention…………………..
3.8.2.4 Associations with reductions in self-criticism…………………….
4. Results……………………………………………………..
4.1 Participant demographic information……………………………….
4.2 Hypothesis 1: Feasibility………………………………………..
4.2.1 Recruitment and retention…………………………………..
4.2.2 Inclusion / exclusion criteria…………………………………..
4.3 Hypothesis 2: Acceptability……………………………………..
4.3.1 Acceptability of assessment methods…………………………….
4.3.2 Acceptability of the intervention……………………………….
4.3.2.1 The intervention as a whole……………………………….
4.3.2.2 Treatment rationale…………………………………….
4.3.2.3 Psycho-education components……………………………..
4.3.2.4 Acceptability and use of specific techniques……………………..
4.3.2.5 Session attendance……………………………………..
4.4 Treatment protocol: fidelity & revisions……………………………..
4.4.1 Fidelity………………………………………………..
4.4.2 Protocol revisions…………………………………………
4.5 Changes in self-criticism and other outcomes………………………….
4.5.1 Therapist effects………………………………………….
4.5.2 Effect of waiting time for intervention……………………………
4.5.3 Hypotheses 3 and 4: Comparison between pre and post-intervention……….
4.5.3.1 Hypothesis 3A, 4 & 5: Primary outcome measures…………………
4.5.3.2 Hypothesis 3B, 4 & 5: Secondary outcome measures……………….
4.5.3.3 Hypothesis 3C, 4 & 5: Comparison between pre and post-intervention for process measures
4.5.3.4 Hypothesis 3C: Associations with reductions in self-criticism…………..
5. Discussion…………………………………………………..
5. 1 Hypothesis 1: Feasibility……………………………………….
5.2 Hypothesis 2: Acceptability……………………………………..
5.2.1 Acceptability of assessment methods…………………………….
5.2.2 Acceptability of the intervention……………………………….
5.3 Hypotheses 3, 4 & 5: Changes in self-criticism and other outcomes and associations between the changes…..
5.3.1 Impact on self-criticism and associated impairment…………………..
5.3.2 Changes in secondary outcome measures………………………….
5.3.3 Changes in process measure………………………………….
5.4 Limitations………………………………………………..
5.5 Strengths…………………………………………………
5.6 Implications……………………………………………….
5.7 Conclusions………………………………………………..
References
Appendices contents page…………………………………………..
Appendix 1. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) original approval (18.11.2014)…..
Appendix 2. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) modification approval (27.02.2015)…..
Appendix 3. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) modification approval (16.07.2015)…..
Appendix 4. Questionnaires completed at each time point…………………..
Appendix 5. Study questionnaires…………………………………..
Appendix 6. Participant feedback questionnaire…………………………
Appendix 7. Measure of frequencies of use of specific intervention techniques since end of treatment collected at two-month follow-up appointment…..
Appendix 8. Flow chart to show participants’ journey and involvement of therapists
Appendix 9. Online recruitment advertisement………………………….
Appendix 10. Participant information sheet……………………………
Appendix 11. Participant consent form……………………………….
Appendix 12. Session protocols……………………………………
Appendix 13. Blank participant formulation worksheet…………………….
Appendix 14. Participant booklets………………………………….
Appendix 15. Post-intervention ratings of how useful participants found the intervention
Appendix 16. Post-intervention ratings of how useful participants found each technique
Appendix 17. Ratings of frequency of use for each technique since end of treatment collected at follow-up appointment…..
Appendix 18. Results of independent t-tests comparing the two therapists on participant measures across time points…..
Appendix 19. Results of linear regressions investigating relationship between (a) length of baseline (time between screening and pre-intervention), (b) time from screening to post-intervention and (c) time from pre to post intervention and change in study measures…..
Appendix 20. Line graphs for secondary outcome measures (PHQ-9, GAD-7, RSES and ‘maladaptive perfectionism) at main study time points…..
Appendix 21. Line graphs for process measures (SCS, ERQ-reappraisal, ERQ-suppression, and BES) at main study points…..
List of Tables
Table 1 Feasibility objectives and outcomes
Table 2 Acceptability of assessment methods and intervention
Table 3 Participant baseline demographic information
Table 6 Process measures: Results of one-way ANOVAs, means and standard deviations and effect sizes
List of Figures
Figure 1 Study flow diagram showing recruitment process
Abstract
Objectives
Self-criticism is a transdiagnostic process that is receiving increased research attention. This uncontrolled pilot study evaluated the feasibility and acceptability of a novel intervention based on Compassion Focused Therapy to reduce self-criticism, as well as investigating changes in a range of outcome and process measures.
Methods
Twenty-three student participants with significant impaired functioning associated with high levels of self-criticism completed a six-session formulation-focused intervention and a two-month follow-up appointment. Sessions were delivered weekly and the majority of techniques focused on increasing self-compassion. Self-report outcome and process measures were collected weekly prior to each session. Acceptability was assessed through qualitative feedback and rating scales.
Results
The intervention was feasible in terms of recruitment and retention of participants, and both the assessment methods and intervention were acceptable to participants. One way repeated measure ANOVAs showed statistically significant differences between pre and post-intervention on outcome measures (self-critical thinking, functional impairment, depression, anxiety, self-esteem and unhealthy perfectionism) and process measures (self-compassion, unhelpful beliefs about emotions and emotion regulation strategies). Participants either continued to improve between post-intervention and follow-up, or the gains were maintained between these two time points for all outcome measures. Effect sizes were medium to large for all outcome and process measures at both post-intervention and follow-up. Pearson correlations indicated that reductions in self-criticism were associated with increases in self-compassion suggesting it could be investigated further as a possible mediator of treatment outcome.
Conclusions
The compassion-focused intervention showed preliminary evidence of effectiveness for self-critical students and was a feasible and acceptable treatment approach.This intervention now requires investigation in a randomised controlled trial.
1. Introduction
1.1 Self-criticism
Self-criticism is a self-evaluative process where individuals judge themselves in a harsh or punitive way (Shahar et al., 2015). Self-criticism is considered to be a common experience; it has been reported across a range of settings including academia (Powers et al., 2011), and within both clinical and non-clinical populations (Baiao et al., 2014). Self-criticism has been described as a transdiagnostic process; high levels of self-criticism are predictive of a wide range of clinical difficulties including depression (Luyten et al., 2007), suicidality (O’Connor & Noyce, 2008), social anxiety (Cox, Fleet & Stein, 2004; Shahar, Doron & Szepsenwol, 2015) and eating disorders (Fennig et al., 2008). The relationship between self-criticism and depression has been a particular focus in previous research; levels of self-criticism have been found to predict depression and global psychosocial impairment in a clinical population after a four-year period (Dunkley et al., 2009). Self-critical individuals also have more difficulties forming and maintaining therapeutic relationships in treatment (Whelton, Paulson & Marusiak, 2007), and have poorer outcomes after treatment for depression (Marshall et al., 2008; Rector et al., 2000).
1.2 The treatment of self-criticism
Recently, specific interventions have been piloted to directly target high levels of self-criticism. Shahar et al (2012) found that an emotion-focused two-chair dialogue technique significantly reduced self-criticism in individuals recruited from university and community advertisements who scored at least one standard deviation above the means reported on the Forms of Self-Criticising/Attacking and Self-Reassuring Scale (FSCRS) by Gilbert et al (2004). These gains were maintained at a six-month follow-up (Shahar et al., 2012). Shahar et al (2015) used a Loving-Kindness Meditation (LKM) intervention with individuals who were ‘above average’ on the 11-item self-critical perfectionism subscale of the Dysfunctional Attitude Scale (SCP-DAS) (de Graaf, Roelofs & Huibers, 2009) and found significant reductions in self-criticism and increases in self-compassion compared to a waitlist control. Other than these studies, research focused on specific self-criticism interventions have been limited. Instead, interventions have been developed targeting overlapping or related constructs such as certain forms of perfectionism, self-esteem and rumination. These constructs will briefly be outlined below, including their relationship with self-criticism and the different treatment approaches designed to target them.
1.3 Constructs related to self-criticism and their treatment
1.3.1 Perfectionism
Self-criticism is often suggested to be a component of certain forms of perfectionism. Different types of perfectionism are thought to exist (Bergman, Nyland & Burns, 2007); for example, some have distinguished between maladaptive ‘self-critical perfectionism’ (SCP) (also called ‘evaluative-concerns’) and ‘positive striving’, a more adaptive perfectionism (Bieling, Israeli & Antony, 2004).SCP has been defined as a “hypersensitivity to perceived excessive external standards and criticism” (Powers et al., 2004, P. 62).Interestingly, Dunkley, Zuroff & Blankstein (2006) found that the Depressive Experiences Questionnaire (DEQ) (Blatt, D’Afflitti & Quinlan, 1976) self-criticism was the only sub-component of SCP that was a unique significant predictor of anxiety, depression and eating disorder symptoms after controlling for the effects of the other SCP subcomponents, suggesting that self-criticism is the key component of SCP that is associated with clinical problems.
Other researchers have drawn a distinction between perfectionism and ‘clinical perfectionism’, the latter of which has been conceptualised to include increased levels of self-critical thinking (Shafran, Cooper & Fairburn, 2002; 2003).Shafran, Cooper & Fairburn (2002) have developed a cognitive behavioural model of clinical perfectionism and CBT interventions have been shown significantly reduce clinical perfectionism (Riley et al., 2007; Steele et al., 2013). As part of these interventions, self-critical thoughts are targeted through psychoeducation, thought challenging and behavioural experiments. Of note, Steele et al (2013) found reductions in both perfectionism and the self-criticism subscale of the DAS (Weissman and Beck, 1978) after a group CBT intervention for psychiatric patients with clinical levels of perfectionism and a variety of Axis 1 diagnoses.
1.3.2 Self-esteem
Self-criticism is associated with lower self-esteem (Thompson & Zuroff, 2004) which in turn is a risk factor for mental health problems, such as depression and anxiety (Sowislo & Orth, 2013)and eating disorders (Cervera et al., 2003). High self-esteem has been defined in terms of a feeling that one is ‘good enough’ with a sense of self-worth (Rosenberg, 1989). In a CBT model of self-esteem, self-criticism is suggested to be a maintaining factor for low self-esteem (Fennell, 1998). Based on this model, a CBT intervention has been developed to improve self-esteem (Fennell, 1998; 2013). Part of this intervention targets self-criticism through thought challenging and behavioural experiments (Fennell, 2013). However, as this intervention contains multiple components, it is unclear to what extent self-criticism is a specific focus, and the impact of CBT for self-esteem on self-critical thinking has not been reported.
1.3.3 Depressive rumination
The relationship between self-criticism and rumination is also important to consider. Depressive rumination is defined as repetitive thinking or analysing about oneself, one’s symptoms or mood, as well as the reasons and implications of one’s problems (Nolen-Hoeksema, 1991; Watkins et al., 2014). Rumination is a risk factor for the onset and maintenance of depression (Nolen-Hoeksema, 2000). Self-critical individuals have a tendency to respond to low mood with more rumination (Spasojevic & Alloy, 2001). Although both self-criticism and rumination are self-focused, and rumination may include self-criticism, rumination is also conceptualised to include a far broader range of content including blaming others. Watkins and Nolen-Hoeksema (2014) conceptualise rumination as a learnt habitual behaviour. Watkins’ Rumination-Focused CBT (RF-CBT; Watkins et al., 2007; 2011) aims to identify warning signs of rumination and practice alternative responses to depressed mood in order to develop more adaptive habits. However, the impact of RF-CBT on self-critical thinking has not been investigated.
Like rumination, self-critical thinking could be conceptualized as a habitual response to, for example, making mistakes. An intervention to target self-criticism could therefore be based on a similar principle; identifying situations that trigger self-criticism and develop more adaptive habits. Research focused on self-compassion suggests that this could be an effective adaptive habit to teach individuals with high levels of self-criticism. This will be discussed further in the section below.
1.4 Self-compassion interventions to target self-criticism
Low levels of self-compassion have been suggested to be a key feature of self-critical individuals (Neff, 2003a). Self-compassion has been associated with lower levels of anxiety and depression, and higher levels of wellbeing and happiness (see Barnard & Curry, 2011; Macbeth & Gumley, 2012 for reviews). Furthermore, self-compassion has been found to partially mediate the relationship between self-criticism and depression (Joeng & Turner, 2015).
In an experimental design, Falconer et al (2014) found that a one-off virtual reality paradigm that focused on practicing a compassionate response to a child avatar from different perspectives led to reductions in self-criticism in individuals who reported high levels of self-criticism as measured by the FSCRS. However, such an approach is not available in most settings as requires virtual reality equipment.
A range of treatment approaches have been developed to increase self-compassion (e.g. Neff & Germer, 2012; Jazaieri et al., 2013; Gilbert, 2009). One of these, Gilbert’s Compassionate Focused Therapy (CFT) has been designed specifically for individuals with high levels of self-criticism and shame (Gilbert, 2009; 2010a). CFT is based on the idea that there are at least three types of emotion regulation systems: a threat-protection system, designed to detect and respond to threats in the environment; a drive-motivation system, designed to direct individuals towards appropriate rewards, and a contentment-soothing-safeness system, designed to regulate feelings of contentment and calm (Gilbert, 2010a). CFT uses a ‘threat/safety strategy’ formulation (Gilbert, 2010c) which focuses on the organisation of these three systems, with a particular focus on threat and safety strategy development (Gilbert, 2010a). In this formulation, an individual’s early experiences lead to the development of key ‘internal’ fears, i.e. fears that an individual has about themselves, and ‘external’ fears, i.e. fears that an individual has about other people or the world. Individuals then develop ‘safety protection strategies’ as a way of coping with these key fears. For example, individuals may use achievement as a way of avoiding negative events or feelings of rejection leading to over-active drive-motivation systems (Gilbert, 2009). Individuals may also engage in self-criticism as a safety strategy that develops, for example, in the context of abuse, bullying or harsh parenting styles (Gilbert, 2009). As a safety strategy, self-criticism has both ‘intended’ consequences such as ‘to learn from mistakes’ and ‘unintended’ consequences, such as ‘worry, anxiety and low mood’ (Welford, 2012). Over time, self-critical individuals become even more highly sensitive to threats and, because they focus most of their attentional resources on detecting and responding to threat, the contentment-soothing-safeness system does not develop properly (Gilbert & Irons, 2005). Thus, self-critical individuals are thought to have over-active threat-protection and drive-motivation systems, and an under-active contentment-soothing-safeness system (Gilbert, 2009). CFT therefore aims to develop the contentment-soothing-safeness system using Compassionate Mind Training (CMT); a range of skills and practices that focus on developing self-compassion (Gilbert, 2009; 2010b).
Self-compassion is thought to consist of a range of attributes including ‘care for well-being’: having the intention and commitment to care about oneself; ‘sensitivity to distress’: being aware and open to one’s distressing experiences; ‘non-judgement’: trying not to judge or condemn one’s thoughts, feelings and behaviours; ‘distress tolerance’: learning to tolerate one’s difficult feelings rather than avoiding them, and ‘sympathy’ and ‘empathy’: being emotionally touched by one’s experiences (Gilbert, 2009). In CMT, individuals are taught to, for example, accept and tolerate their emotional experiences and develop more compassionate beliefs about distressing and difficult emotions. This is particularly important given that, in line with previous research about ‘maladaptive’ perfectionism, self-critical individuals may have unhelpful beliefs about experiencing or expressing negative emotions (Rimes & Chalder, 2010), and as a result, may have a tendency to suppress difficult emotions. Specific CMT exercises include using compassionate thought records to develop a ‘compassionate reframe’ or a compassionate reappraisal of difficult situations (Gilbert, 2005). This technique may help individuals increase their use of ‘cognitive reappraisal’, an adaptive emotion regulation strategy (Gross, 1998). CMT also includes the use of imagery, for example, developing a ‘compassionate other’ image, which has been shown to reduce self-reported self-criticism in individuals with depression (Gilbert & Irons, 2004).
Although there is growing evidence-base for CMT for individuals with severe and enduring mental health problems (Gilbert & Procter, 2006; Mayhew & Gilbert, 2008), the CFT approach has not yet been applied to individuals with specific difficulties with self-criticism. This study aimed to develop a novel intervention based on CFT to target self-criticism in a student population as a form of early intervention.
1.5 Student mental health
Half of all mental health problems start by mid-teens and three quarters by the age of 24 years (Kessler et al., 2007). Furthermore, in 2012 approximately 80% of university students were aged between 18 (and under) and 24 years (Higher Education Statistics Agency, 2016). Therefore, providing interventions to university students is a potential method for addressing mental health problems at an early stage before they may become chronic.
Whilst at university, students face a range of different stressors, such as managing the transition from school to university, their academic studies, and issues related to diversity and relationships (Hurst et al., 2013). These burdens have been positively associated with depression (Mikolajczyk et al., 2008). In a UK student survey, 31% of females and 23% of males reported to have had depression in the preceding year (El Ansari et al., 2011). This is similar to the rates of depression in the general population (Blanco et al., 2008). However, the mental health of students has become a particular concern for universities (Castillo & Schwartz, 2013); both the number and severity of mental health problems in this population is increasing (Gallagher, 2008). Furthermore, mental health problems can have a negative impact on academic performance (Brackney & Karabenick, 1995) or lead students to prematurely end their education (Kessler et al., 1995). Mental health problems in young adulthood have also been associated with a number of negative outcomes including fewer employment opportunities (Eisenberg, Goldberstein & Gollust, 2007). Given this context, it has been suggested that university is a promising setting for the early intervention of mental health problems (Hunt & Eisenberg, 2010).
One advantage of targeting self-criticism is that it is a transdiagnostic factor associated with a range of different psychological problems. It can also be present and impairing in the absence of a full clinical disorder and therefore addressing it could be a form of primary prevention for mental health problems. For students, learning to effectively manage self-criticism is not only important because of its relationship to mental health problems, but it has also been found to be associated with lower levels of goal pursuit (Powers et al., 2011), which in turn could impact on a student’s academic performance. Furthermore, in academic settings there is a high prevalence of perfectionistic tendencies (Arpin-Cribbie et al., 2008) and maladaptive forms of perfectionism have been associated with higher levels of anxiety and depression in students (Kawamura et al., 2001). There may also be particular benefit in helping students increase their self-compassion; it has been associated with lower levels of procrastination (Williams, Stark & Foster, 2008), personal distress (Neff & Pommier, 2012), and an increased sense of self-efficacy (Iskender, 2009). Self-compassion has also been found to act as a ‘buffer’ against the difficulties associated with the transition to university such as homesickness (Terry, Leary & Mehta, 2014).
2. Aims
The present study involved the development of a new six-session intervention, drawing predominantly on methods from CFT, to reduce self-criticism in students with high levels of self-criticism. An uncontrolled pilot study was conducted with the following specific aims:
- To assess the acceptability and feasibility of the new intervention and assessment methods to investigate the impact of this intervention.
- To investigate changes in self-criticism, impaired functioning, depression, anxiety, self-esteem and ‘maladaptive’ perfectionism, comparing pre-treatment scores with those at post-treatment and two-month follow-up.
- To gain preliminary information about possible mechanisms of change including self-compassion, beliefs about emotions and emotion regulation strategies (‘cognitive reappraisal’ and ‘expressive suppression’), as these are all addressed in CFT.
2.1 Hypotheses
It was hypothesized that:
- The intervention would be feasible to deliver in terms of the recruitment and retention;
- Participants would find both the intervention and assessment methods acceptable;
- At post-treatment compared to baseline participants would report:
- Lower levels of self-criticism and associated impairments in functioning;
- Lower levels of depression, anxiety and ‘maladaptive’ perfectionism and higher levels of self-esteem;
- Higher levels of self-compassion and ‘cognitive reappraisal’ and a reduction in ‘expressive suppression’ and unhelpful beliefs about the unacceptability of negative emotions. Linked to this, it was hypothesised that reductions in self-criticism would be associated with increases in self-compassion, ‘cognitive reappraisal’ and reductions in ‘expressive suppression’ and unhelpful beliefs about emotions.
- There would be significantly larger improvements in key outcomes from pre-treatment to post-treatment than between screening and pre-treatment assessments.
- The gains made in the intervention would be maintained over time (i.e. between post-treatment and follow-up).
3. Method
3.1 Ethical Approval
Ethical approval was gained from the King’s College London (KCL) Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (see Appendices 1, 2 and 3).
3.2 Design
The study was an uncontrolled pilot study of a new intervention. A mixed qualitative and quantitative design was utilized in order to collect participant feedback about the acceptability of the intervention and assessment methods. Standardised questionnaire measures of self-criticism and other outcomes were completed at screening, prior to the weekly intervention sessions and at the 2-month follow-up appointment (see Appendix 4 for details about which questionnaires were completed at each time-point).
3.3 Participants
All participants were KCL students (see below for the inclusion and exclusion criteria). In regards to point 3 of the inclusion criteria, all participants had high scores on the self-criticism measures, however, an exact cut-off was not specified. Part of the development work of this study was to identify suitable questionnaire cut-off scores for inclusion as no previous studies were identified using this strategy.
Inclusion Criteria
|
The target sample size was 16-25 participants. This was in line with recommendations regarding sample sizes for pilot studies assessing intervention efficacy in a single group of participants (Hertzog, 2008).
3.4 Measures
Questionnaires were completed online using an online survey tool, Survey Monkey. To reduce burden placed on participants, the complete data set was only completed at session 1, 3, 6 and follow-up (see Appendix 4). Of note, two self-criticism questionnaires were completed at each time point. Two additional self-criticism questionnaires were completed once prior to session 1 to aid with the development of individualized formulations. The questionnaires are described below (see Appendix 5 for copies). The Cronbach’s alphas of the measures were examined at pre-intervention to confirm their internal consistency. Only the ‘doubts about actions’ subscale of the Multi-Dimensional Perfectionism Scale (MDPS) and the ‘inadequate self’ subscale of the FSCRS were below 0.70. Thus, the other measures were within satisfactory limits (Nunnaly & Bernstein, 1994).
3.4.1 Primary outcome measures
The Habitual Index of Negative Thinking (HINT) (Verplanken et al., 2007)
The HINT has 12 items measuring habitual negative self-thinking. Participants rated their agreement on a 5-point Likert scale ranging from “Strongly disagree” to “Strongly agree”. A score was given out of 60; higher scores represented higher levels of negative self-thinking. In previous research the internal consistency was 0.95 (Verplanken et al., 2007); in this study Cronbach’s alpha= 0.88.
Self-Critical Rumination Scale (SCRS) (Smart, Peters & Baer, 2015)
The SCRS has 10 items measuring self-critical rumination. Participants rated their agreement on a 5-point Likert scale ranging from “Strongly disagree” to “Strongly agree”. A score was given out of 40; higher scores represented higher levels of self-critical rumination. In previous research the internal consistency was 0.92 (Smart et al., 2015); in this study Cronbach’s alpha= 0.75.
Work and Social Adjustment Scale (WASAS) (Mundt et al., 2002)
The WASAS has 5 items and was used to measure the impact of self-criticism on different areas of an individual’s life. Each item focused on a different area of functioning such as work and home management.Participants rated their agreement on a 9-point Likert scale ranging from “Not at all” to “Very severely”.In previous research the internal consistency ranged from 0.70 to 0.94 (Mundt et al., 2002); in this study Cronbach’s alpha= 0.80. A score was given out of 40; higher scores represented more impaired levels of functioning. Scores of 10 and above are thought to indicate significant functional impairment (Mundt et al., 2002). As there is little evidence about scores on measures of self-criticism that would indicate a clinically significant level of self-criticism, the WASAS was used as the measure for calculating the proportion of the participants whose scores fell below clinical cut-off (i.e. WASAS score of 9 and below) after treatment.
3.4.2 Secondary outcome measures
Patient Health Questionnaire (PHQ-9) (Kroenke, Spitzer & Williams, 2001)
The PHQ-9 has 9 items measuring depressive symptoms over the last 2 weeks. Participants rated their agreement on a 4-point Likert scale ranging from “Not at all” to “Nearly every day”. A score was given out of 27; higher scores represented more severe depression. In previous research the internal consistency ranged from 0.86 to 0.89 (Kroenke et al., 2001); in this study Cronbach’s alpha= 0.83.
Generalised Anxiety Disorder (GAD-7) (Spitzer et al., 2006)
The GAD-7 has 7 items measuring anxiety over the last 2 weeks. Participants rated their agreement on a 4-point Likert scale ranging from “Not at all” to “Nearly every day”. A score was given out of 21; higher scores represented more severe anxiety. In previous research the internal consistency was 0.92 (Spitzer et al., 2006); in this study Cronbach’s alpha= 0.90.
Rosenberg’s Self-Esteem Scale (Rosenberg, 1965)
The RSES has 10 items measuring global self-esteem. Participants rated their agreement on a 4-point Likert scale ranging from “Strongly agree” to “Strongly disagree”. Items 3, 5, 8, 9 and 10 were reverse scored. In previous research the internal consistency ranged between 0.72 – 0.88 (Rosenberg, 1965); in this study Cronbach’s alpha= 0.81. A score was given out of 30; higher scores represented higher self-esteem.
The Multi-Dimensional Perfectionism Scale (MDPS) (Frost et al., 1990)
The MDPS has 35 items measuring perfectionism. Participants rated their agreement on a 5-point Likert scale ranging from “Strongly agree” to “Strongly disagree”. There are 6 subscales: ‘concern over mistakes’ (CM), ‘personal standards’ (PS), ‘parental expectations’ (PE), ‘parental criticism’ (PC), ‘doubts about actions’ (DA) and ‘organisation’ (O). For this study, the CM, DA, PE and PC subscales were totalled to measure ‘maladaptive’ perfectionism (Range: 22 – 110) (Stumpf & Parker, 2000). In previous research internal consistency ranged from 0.77 to 0.93 (Frost et al., 1990); in this study subscales Cronbach’s alpha ranged from 0.67 – 0.90.
3.4.3 Process measures
Self-Compassion Scale (SCS) (Neff, 2003b)
The SCS has 26 items divided into 6 subscales: 3 measure ‘self-compassion’ (‘common humanity’, ‘self-kindness’ and ‘mindfulness’) and 3 measure ‘coldness towards the self’ (‘self-judgement’, ‘over identification’ and ‘isolation’). Participants rate their agreement on a 5-point Likert scale ranging from “Almost never” to “Almost always”. Items from the 3 ‘coldness towards the self’ subscales are reverse scored. A score was given out of 130; higher scores represented higher levels of self-compassion. In previous research the internal consistency was 0.97 (Neff & Germer, 2013); in this study Cronbach’s alpha= 0.88.
The Emotion Regulation Questionnaire (ERQ) (Gross & John, 2003)
The ERQ has 10 items divided into 2 subscales measuring individual differences in the use of 2 emotion regulation strategies: ‘cognitive reappraisal’ and ‘expressive suppression’ (referred to as ‘reappraisal’ and ‘suppression’ in following sections). Participants rate their agreement on a 7-point Likert scale ranging from “strongly disagree” to “strongly agree”. Higher scores indicated a greater use of this type of strategy. In previous research the internal consistency was 0.79 for ‘reappraisal’ and 0.73 for ‘suppression’ (Gross & John, 2003); in this study Cronbach’s alpha was 0.79 for ‘reappraisal’ and 0.80 for ‘suppression’.
Beliefs about Emotions scale (BES) (Rimes & Chalder, 2010)
The BES has 12 items measuring the unacceptability of experiencing or expressing negative emotions. Participants rated their agreement on a 7-point Likert scale ranging from “totally agree” to “totally disagree”. A score was given out of 72; higher scores represented stronger beliefs about the unacceptability of negative emotions. In previous research the internal consistency was 0.91 (Rimes & Chalder, 2010); in this study Cronbach’s alpha= 0.83.
3.4.4 Measures to aid formulation
The Forms of Self-Criticizing/Attacking and Self-Reassuring Scale (FSCRS) (Gilbert et al., 2004)
The FSCRS has 22 items measuring different forms of self-critical and self-reassuring responses to a setback. It has 3 subscales: ‘inadequate self’ (9 items; internal consistency = 0.90), ‘hated self’ (5 items; internal consistency = 0.86), and ‘self-reassurance’ (8 items; internal consistency = 0.86). Participants rated their agreement on a 5-point Likert scale ranging from “Not at all like me” to “Extremely like me”. In this study, Cronbach’s alpha were 0.62 for ‘inadequate self’, 0.83 for ‘reassure self’ and 0.75 for ‘hated self’.
The Functions of Self-Criticizing/Attacking Scale (FSCS) (Gilbert et al., 2004)
The FSCS has 21 items examining reasons why individuals may be self-critical. It has 2 subscales: ‘self-correction’ (13 items; internal consistency = 0.92) and ‘self-persecution’ (8 items; internal consistency = 0.92). Participants rated their agreement on a 5-point Likert scale ranging from “Not at all like me” to “Extremely like me”. In this study Cronbach’s alpha for the whole scale was 0.72.
3.4.5 Participant feedback
Feedback was collected at various points throughout the study. In session 1, participants rated how ‘logical’ the intervention approach seemed to be on a 5-point Likert scale where 0 was “not at all” and 4 was “extremely”. Feedback was also collected online through Survey Monkey after the last intervention session (completion was optional). The survey was devised for the purpose of this study and contained both quantitative rating scales and open-ended questions (see Appendix 6). As part of this questionnaire, participants were asked to rate different aspects about the intervention on a 5-point Likert scale where 1 was “strongly disagree” and 5 was “strongly agree”. Participants also rated the usefulness of techniques on 5-point Likert scale where 0 was “not at all” and 4 was “very much”. At follow-up, participants rated how often they had used each technique since the end of treatment using a 6-point Likert scale where 0 was “not at all” and 5 was “every day” (see Appendix 7).
3.5 Procedure
The current study was completed by two trainee clinical psychologists. Both were involved equally in all stages of the study design, procedure and participant data collection. Therapist 1 (author) analysed the feasibility, acceptability and pre and post outcome data for the current study. Therapist 2 analysed the data that was collected from a qualitative interview that took place immediately prior to session 1. Appendix 8 displays a flow chart highlighting the participants’ journey through the study and the tasks completed by both therapists.
Two recruitment drives were completed; the first took place between February – March 2015, the second took place in September 2015. For each drive, the study was advertised twice through a fortnightly email about current KCL research projects and further information about the study was included on the KCL intra-net (see Appendix 9 for advertisement). Individuals who responded were sent a Participant Information Sheet (see Appendix 10) and a link to the screening questionnaires.
Individuals who appeared to meet the inclusion criteria were offered a telephone screening to further assess eligibility. During this screening, past and current mental health problems were assessed using the latest version of the Mini International Neuropsychiatric Interview (M.I.N.I) (English Version 6.0.0), a brief structured interview that assesses DSM-IV and ICD-10 psychiatric disorders through different modules (Medical Outcome Systems, 2016). The M.I.N.I has been validated against other clinical interviews and expert opinion across different European countries (Lecrubier et al., 1997; Sheehan et al., 1997; Amorim et al., 1998; Sheehan et al., 1998). If any risk issues were identified through the M.I.N.I ‘suicidality’ section, a further detailed risk assessment was completed.
Decisions about eligibility were made after discussions with the research team and then communicated to the individual by either phone or email. If they still wished to take part, participants then completed a participant consent form (see Appendix 11). Individuals who were not eligible were signposted to appropriate alternative sources of support.
Two trainee clinical psychologists delivered the intervention supervised by a consultant clinical psychologist. Treatment was offered on a first-come-first-served basis but also took account of participants’ availability to complete a course of weekly sessions. The average time between screening and session 1 was 13 weeks (SD=7.62).
Measures were completed weekly through Survey Monkey (see Appendix 4). Immediately prior to session 1, a semi-structured interview was conducted by the therapist about the participant’s experiences of self-critical thinking. This ranged from 45 minutes to 1.5 hours. These interviews were used for therapist’s 2 research project, however, the information gained was also utilised in session 1.
3.6 Intervention
The intervention consisted of six 1-hour individual sessions (seeAppendix 12 for session protocols). Sessions were delivered approximately weekly. The time between some of the sessions varied in length; reasons for this included university holidays and sickness. Every session was audio-recorded and listened to by the therapist’s supervisor to ensure fidelity to the protocol and for supervision purposes. A telephone follow-up appointment took place approximately 2-months post-intervention.
In session 1, the information gathered during the semi-structured interview was used to develop an individualized formulation with the participant based on Gilbert’s (2010c) ‘threat/safety strategy formulation’ (see Appendix 13). Participants were given psychoeducation about the self-compassion approach, including information about the 3-emotion regulation systems (Gilbert, 2009; 2010a). Finally, as part of the acceptability objectives, participants were given an overview of the intervention and rated how ‘logical’ the treatment rationale was.
The remaining sessions followed the same general structure: agenda setting and check in, review of the homework tasks, completion of an experiential exercise to practice a new technique and, finally, a summary of the session and homework setting. The sessions covered techniques primarily aimed at helping participants to reduce and cope with their self-critical thinking, as well as developing self-compassion. Throughout the sessions, where appropriate, links were made to the both the original formulation and the 3 emotion-regulation systems. Participants were given a booklet at the end of sessions 1-5 with further details about the session content (see Appendix 14). The treatment protocol and booklets were designed by the two trainee psychologists providing the intervention and their primary supervisor, drawing heavily from Gilbert’s Compassionate Mind approach as well as general cognitive behavioural therapy principles and research evidence about self-criticism.
3.7 Feasibility & acceptability objectives
Feasibility and acceptability were assessed through specific objectives which were further operationalized into specific outcomes (Thabane et al., 2010) (see Table 1 & 2).
Table 1 Feasibility objectives and outcomes
| Objective | Specific Objective | Outcome |
| Recruitment | How easy is it to recruit eligible participants? |
|
| Is the inclusion/exclusion criteria appropriate for the target population? |
|
|
| Retention | Do participants complete the intervention? | Number of drop outs:
|
Table 2 Acceptability of assessment methods and intervention
| Objective | Specific Objective | Outcome |
| Assessment methods | How acceptable are the:
|
|
| Intervention | How acceptable is the intervention content?
|
|
| How acceptable are the practical aspects of the sessions? |
|
3.8 Data preparation and analysis
3.8.1 Hypotheses 1 & 2: Feasibility & acceptability
Written responses to the open-ended feedback questions were analysed using brief content analysis (Mayring, 2000). Inductive category development was utilised whereby responses were read through and categories were defined based on the material. After reading through approximately 50% of the text for each question, these categories were refined before the entire text was analysed using the final categories.
3.8.2 Hypotheses 3, 4 & 5: Changes in self-criticism and other outcomes
As there were only 11 missing items across the dataset, mean item scores were computed and input for missing items (Fox‐Wasylyshyn and El‐Masri, 2005). As multiple tests were used, a more conservative cut-off p value ≤0.01 was used to indicate statistical significance; p values between 0.01 and 0.05 were considered to be a ‘non-significant trend’. As well as this, in line with the assumption of equal standard deviations, a rule of thumb was used for t-tests and ANOVAs to check that the smallest standard deviation between, for example, therapists, was not less than half of the largest standard deviation (Howell, 2012). Throughout, pre-intervention is defined as session 1 as this was the first time point that participants completed all measures; post-intervention is defined as session 6. Of note, a statistician was consulted prior to data analysis.
3.8.2.1 Therapist effects
Independent t-tests were completed to determine if there were differences in outcomes between therapists at each time point. The data was assessed to confirm that it met specific parametric assumptions. Although there were 3 extreme data-points, the inclusion and exclusion of them resulted in no changes to conclusions and they were therefore included in the analyses. Normality was assessed using the Shapiro-Wilk test. A number of time points for therapist (2) violated this assumption. However, as independent t-tests are considered ‘robust’ to deviations from normality, and the non-parametric Mann-Whitney U test resulted in no changes to the final conclusions, parametric t-tests were used. For each t-test, homogeneity of variances was also confirmed.
3.8.2.2 Effects of waiting for intervention
Linear regressions were used to investigate whether the time between screening and pre-intervention and the subsequent time to complete the intervention (time between screening and post-intervention and time between pre and post-intervention) predicted change in any of the study measures. It was confirmed that the data met the following assumptions for linear regressions: linearity, independence of observations, no significant outliers, homoscedasticity, and residuals (errors) were approximately normally distributed.
3.8.2.3 Comparison between pre and post-intervention
To examine the effect of the intervention on the study measures separate repeated measures ANOVAs were conducted for each measure with time as the repeated measure factor. The time points included were screening (if completed), pre-intervention, mid-treatment (session 3), post-intervention and follow-up. When a significant effect of time was found, planned pairwise comparisons were completed to determine whether there were significant differences between measures at the end of the intervention and follow-up compared with pre-intervention. A further t-test was conducted to investigate whether gains were maintained between post-intervention and follow-up. Contrasts between screening and pre-intervention were also completed to determine whether there were any significant changes during the baseline period prior to treatment.
Effect sizes were calculated using Cohen’s d and interpreted using the following cut-offs: ‘negligible’ effect <0.2; small effect ≥0.2, medium effect ≥ 0.5, large effect ≥ 0.8. Effect sizes for post-intervention and follow-up were calculated by dividing the mean differences between post and pre-intervention and follow-up and pre-intervention by the mean standard deviations at pre-intervention. Effect sizes were also calculated for measures collected at both screening and pre-intervention by dividing the mean difference between pre-intervention and screening by the mean standard deviation at screening. This was done to see how participants changed over time without treatment; these effect sizes are referred to as ‘pre-treatment changes’.
Across the dataset, there was 1 extreme outlier. As there were no changes to final conclusions without this data point, it was included in the analyses. Normality was assessed using the Shapiro-Wilk test. Although a number of time-points for the PHQ-9 and GAD-7 violated this assumption, since repeated measures ANOVA are considered ‘robust’ to deviations from normality and the non-parametric Friedman test resulted in no changes to the final conclusions, the ANOVAs are presented. Where the Mauchly’s test of sphericity indicated that the assumption of sphericity had been violated, Greenhouse-Geisser was used to correct the ANOVAs.
For outcome measures that were completed at both screening and pre-intervention, paired t-tests were also completed to determine whether there were statistically significant differences between the mean change in scores between screening and pre-intervention and between pre-intervention and post-intervention. Change in scores were computed by pre-intervention scores minus screening scores and post-intervention scores minus pre-intervention scores.
3.8.2.4 Associations with reductions in self-criticism
Pearson correlations were used to determine whether reductions in self-criticism were associated with increases in self-compassion and ‘reappraisal’, and reductions in ‘suppression’ and unhelpful beliefs about emotions. For this analysis, change in scores between pre-intervention and post-intervention were used.
4. Results
The results are presented in five different sections: participant baseline demographic information, feasibility and acceptability objectives and outcomes (see Table 1 & 2), details about the treatment protocol (fidelity and revisions), and descriptive statistics and statistical analyses for outcome data.
4.1 Participant demographic information
Table 3 summarizes baseline demographic information. The majority of participants were Caucasian female postgraduate students. Although only 7 participants had a current mental health diagnosis (anxiety and/or depression), 13 participants had a past diagnosis of depression.
Table 3 Participant baseline demographic information
| Characteristics | |
| Age, mean (SD), years | 25.3 (6.16) |
| Sex, n (%) | |
| Female | 19 (82.61) |
| Male | 4 (17.39) |
| Ethnicity, n (%) | |
| Caucasian | 17 (73.91) |
| Non-Caucasian | 6 (26.09) |
| Current antidepressant medication, n (%) | 2 (8.70) |
| Current Psychiatric Diagnoses at screening, n (%) | |
| None | 16 (69.57) |
| Depression | 1 (4.35) |
| Social phobia | 1 (4.35) |
| Generalised anxiety disorder (GAD) | 1 (4.35) |
| Social phobia & GAD | 1 (4.35) |
| Depression, social phobia & GAD | 1 (4.35) |
| Depression, agoraphobia, social phobia & GAD | 1 (4.35) |
| Depression, agoraphobia, obsessive compulsive disorder & GAD | 1 (4.35) |
| Past diagnosis of depression, n (%) | 13 (56.52) |
| Stage at university | |
| Undergraduate | 7 (30.43) |
| Postgraduate | 16 (69.57) |
4.2 Hypothesis 1: Feasibility
4.2.1 Recruitment and retention
Figure 1 displays the recruitment and retention numbers for this study. A sufficient number of eligible participants were recruited and subsequently completed the intervention.
Figure 1 Study flow diagram showing recruitment process
Responded to online advertisement (n=176)
Excluded (n=17)
- Lack of distress or significant impairment (n=4)
- Unsuitable level of English language (n=3)
- Alcohol dependence (n=3)
- Level of risk (n=2)
- Availability issues (n=2)
- Anorexia nervosa (n=1)
- Not stable medication (n=1)
- Receiving another intervention (n=1)
Completed screening questionnaires (n=93)
Offered telephone screening (n=68)
Assessed for eligibility (n=47)
Consented (n=30)
Withdrew prior to starting treatment (n=6)
- Change in personal circumstance (n=1)
- Started student counselling (n=1)
- Other family commitments (n=1)
- Unknown reasons (n=3)
Started treatment (n=24)
Did not complete treatment (n=1)
- Withdrew after session 2 due to life event
Completed treatment (n=23)
Complete two-month follow-up measures (n=23)
Attended telephone follow-up appointment (n=22)
4.2.2 Inclusion / exclusion criteria
The inclusion / exclusion criteria resulted in a group of participants who were all experiencing significant distress or impairment as a result of their self-criticism and were able to complete the intervention. There was therefore no indication that the criteria would need adjusting for a follow-on study.
4.3 Hypothesis 2: Acceptability
Twenty-one of the 24 participants completed the feedback questionnaire about the acceptability of the assessment methods and intervention. The open-ended questions were optional and therefore not always completed by all 21 participants.
4.3.1 Acceptability of assessment methods
Qualitative analysis revealed that the telephone screening appointment provided participants with a helpful introduction to the study and therapists. Some participants suggested that they would have preferred to complete this appointment face-to-face rather than over the phone due to the sensitive nature of some of the questions.
All participants completed the outcome measures at each time point (see Appendix 4). The qualitative analysis revealed that some participants thought that there were too many questionnaires in the full questionnaire pack. Some participants described the weekly questionnaires as “repetitive” to complete.
4.3.2 Acceptability of the intervention
4.3.2.1 The intervention as a whole
Results from the feedback ratings about the usefulness of the intervention are presented in Appendix 15. Of the 21 participants who completed these ratings, 100% of participants “agreed” or “strongly agreed” that the intervention was useful and that they would recommend it to others with high levels of self-criticism. Nineteen participants (90.5%) “agreed” or “strongly agreed” that their therapist understood their needs. Nineteen participants (90.5%) “agreed” or “strongly agreed” that the intervention reduced their self-criticism and 95.2% (n=20) “agreed” or “strongly agreed” that they had improved their ability to cope with it. In line with this, the qualitative analysis revealed that the intervention helped participants learn about the causes and negative impacts of self-criticism, as well as increasing their awareness and control over it. Seventeen participants (81%) “agreed” or “strongly agreed” that the intervention improved their self-compassion. Qualitative feedback revealed that participants had learnt how to use self-compassion towards their self-criticism as well as towards their distress more generally. For the single participant who had not agreed with the statements that the intervention had helped to reduce self-criticism or their ability to cope with it had, nevertheless, indicated that the intervention was helpful, their feedback about “the most important thing” about the intervention was inspected. This indicated that they had learned to view things in in a more positive light instead of focusing on the negative and that mental health requires effort and practice and should not be neglected or disregarded.
4.3.2.2 Treatment rationale
In session one 90.5% of participants (n=19) described the intervention rationale as either “very” or “extremely” ‘logical’ (Mean= 3.60, SD= 0.56).
4.3.2.3 Psycho-education components
The mean percentage of the weekly booklets read by participants was 79.5% (SD= 27.51).In the qualitative analysis participants described them as clear and comprehensive and as a useful way of recapping on the techniques covered in the sessions.
4.3.2.4 Acceptability and use of specific techniques
The mean time spent practicing techniques each week was 140.8 mins (SD= 155.58). Results from the ratings about the usefulness of each technique are presented in Appendix 16. All techniques were rated as at least “somewhat” useful by most of the participants. ‘Decentering’ and ‘compassionate reframes’ received the greatest proportion of the two highest usefulness ratings (both 76%, n=16). Relaxation had the smallest proportion of the two highest ratings, although 38% of participants (n=8) rated it as very useful.
At follow-up, 100% of participants who attended the telephone follow-up (n=22) had been using at least 1 of the techniques during the time between post-intervention and follow-up (see Appendix 17 participants’ reports of technique usage at follow-up). Fifteen participants (68%) had been using either ‘decentering’ or ‘compassionate behaviours’ at least “once a week”. Thirteen participants (59.3%) had been using ‘compassionate reframes’ at least “once a week”. Thus, ‘compassionate reframes’, ‘decentering’ and ‘compassionate behaviours’ were the most frequently used techniques. In the follow-up session, the majority of participants commented that the ‘compassionate reframe’ had become fairly automatic rather than a deliberate process each time.
4.3.2.5 Session attendance
Across all treatment phases, there were 16 cancelled and rearranged appointments. No sessions were missed without prior warning. The qualitative analysis revealed that the majority of participants could not identify anything that could have been changed about the delivery of the intervention to improve participation (n=16, 76.2%). Specific suggestions described by participants were offering sessions at a different point in the academic year (although further explanation as to why was not given), as well as offering longer sessions or sessions fortnightly, in the evenings or during weekends. Most participants felt the number of sessions had been appropriate; only 1 participant suggested that they would have preferred 1-2 additional sessions.
4.4 Treatment protocol: fidelity & revisions
4.4.1 Fidelity
For 21 participants, the full treatment protocol was followed. There were 2 participants whose treatment deviated (slightly) from the protocol. The first participant required a longer time to go through the ‘compassionate self’ technique (across 2 sessions rather than 1 session) and was therefore offered an additional telephone appointment to finalise the session 6 action plan. The second participant was slower to engage with the techniques practiced in the first few sessions and the decision was taken to support them using those techniques rather than practising new methods in session 5 or 6, although they received information about all techniques in the booklets.
4.4.2 Protocol revisions
The feedback and engagement of the first 4 participants were discussed in supervision and, based on these discussions, there were 3 minor changes to the treatment protocol. Firstly, the ‘self-criticism summary’ was made into a homework task after session 1 to allow more time in session 2 to practice the ‘compassionate reframe’. Secondly, in order to support participants to access their ‘compassionate self’ specific participant responses were incorporated into a script which was read and audio-recorded by the therapist. Finally, the ‘loving-kindness meditation’ was incorporated into the session 6 protocol, rather than given as a homework task.
4.5 Changes in self-criticism and other outcomes
4.5.1 Therapist effects
Independent t-tests revealed that at session 1, there was a significant difference in ‘suppression’ scores between therapist (1) (M= 11.73, SD= 5.71) and therapist (2) (M= 17.67, SD= 3.70); [t(21)= -2.99, p= 0.007]. No other statistically significant differences were found (see Appendix 18).
4.5.2 Effect of waiting time for intervention
Linear regression analyses showed that length of the baseline period, the time between screening and post-treatment and the time between pre-treatment and post-treatment were not significantly associated with the change in any of the study measures (see Appendix 19).
4.5.3 Hypotheses 3 and 4: Comparison between pre and post-intervention
The Results of one-way repeated ANOVAs for primary, secondary and process measures are displayed in Table 4, 5, & 6 respectively. Results of the subsequent planned pairwise comparisons are summarised below.
4.5.3.1 Hypothesis 3A, 4 & 5: Primary outcome measures
In line with hypotheses, there were statistically significant reductions between pre and post-intervention and between pre-intervention and follow-up for all primary outcome measures (p values ≤0.002). There were also statistically significant reductions between post-intervention and follow-up (p values ≤0.009) (Figures 2, 3 & 4 display mean scores for the HINT, SCRS and WASAS at main study time points). The Cohen’s d indicated that the intervention had a large effect size for self-criticism at both post-intervention and follow-up, compared with a small effect size for changes over the pre-treatment period. For impaired functioning there was a small effect size for the pre-treatment period, medium effect size from pre-treatment to post-intervention and a large effect size from pre-treatment to follow-up. No significant changes in the primary outcome measures were found over the baseline period between screening and pre-intervention (p values >0.08). Comparing change during the baseline period with the treatment period directly, paired t-tests indicated significantly larger reductions in pre- to post-treatment mean scores than screening to pre-treatment changes for the HINT [t(22)= -6.23, p<0.001], the SCRS [t(22)= -8.24, p<0.001], and the WASAS [t(22)= -5.07, p<0.001].
At post-intervention 8/23 (35%) of participant’s impaired functioning related to self-criticism reduced to below sub-clinical cut-off (Mundt et al., 2002). At follow-up, this had increased to 14/23 (61%) of participants.
Table 4 Primary outcome measures: Results of one-way ANOVAs, means and standard deviations and effect sizes
| Mean scores (standard deviations) | ANOVA | Effect sizes | |||||||||||
| Screening | Session 1 (Pre) | Session 2 | Session 3 | Session 4 | Session 5 | Session 6 (Post) | Follow-up | F (4, 88) | p-value | Pre-treatment changes (Pre – Screening) | Post – Pre | FU – Pre | |
| Habitual Index of Negative Thinking | 48.91
(5.09) |
47.35
(7.30) |
49.39 (5.15) | 46.52
(6.69) |
45.00 (5.05) | 43.00 (5.73) | 41.70
(5.76) |
37.35
(6.70) |
22.76 | <0.001 | -0.31 | -0.77 | -1.37 |
| Self-Critical Rumination Scale (i) | 32.13
(4.42) |
31.35
(4.83) |
31.04 (4.79) | 28.48
(5.60) |
27.48 (4.91) | 26.26 (5.75) | 23.61
(4.75) |
20.61
(5.47) |
36.93
(2.42, 53.30) |
<0.001 | -0.18 | -1.60 | -2.22 |
| Work and Social Adjustment Scale | 21.39
(6.79) |
18.48
(8.63) |
20.30 (7.86) | 17.70
(7.25) |
17.26 (7.68) | 15.87 (8.82) | 12.39
(7.15) |
9.83
(6.81) |
20.65 | <0.001 | -0.43 | -0.71 | -1.00 |
Notes:
Scores for session 2, 4 and 5 are included for information and were not included in any of the analyses.
(i) Greenhouse-Geisser correction applied & degrees of freedom listed in table; FU: Follow-up.
Figure 2 Line graph to show mean scores for the Habitual Index of Negative Thinking (HINT) at screening, pre-intervention, post-intervention & follow-up (one standard deviation error bars)
Figure 3 Line graph to show mean scores for the Self-Critical Rumination Scale (SCRS) at screening, pre-intervention, post-intervention & follow-up (one standard deviation error bars)
Figure 4 Line graph to show mean scores for the Work and Social Adjustment Scale (WASAS) at screening, pre-intervention, post-intervention & follow-up (one standard deviation error bars)
4.5.3.2 Hypothesis 3B, 4 & 5: Secondary outcome measures
In line with hypotheses, there were statistically significant differences between pre and post-intervention and between pre-intervention and follow-up for all secondary outcome measures (p values ≤0.005) (see Appendix 20 for line graphs displaying mean scores for the PHQ-9, GAD-7, RSES and ‘maladaptive’ perfectionism at main study time points).Participants reported lower levels of depression, anxiety and ‘maladaptive’ perfectionism, and higher levels of self-esteem at post-intervention and follow-up compared with pre-intervention.For depression, anxiety and self-esteem there was no significant further change between post-intervention and follow-up. There was a trend that participants reported lower levels of ‘maladaptive’ perfectionism between post-intervention and follow-up (p= 0.03).Cohen’s d indicated that the intervention had a medium effect size for depression at both post-intervention and follow-up, compared with a ‘negligible’ effect size for change over the pre-treatment period. For anxiety, there was a small effect size for change over the pre-treatment period, medium effect size at post-intervention and a large effect size at follow-up. For self-esteem, there was a small effect size for change over the pre-treatment period and a large effect size at both post-intervention and follow-up.The effect sizes for ‘maladaptive’ perfectionism were medium at post-intervention and large at follow-up.
No significant differences were found for depression, anxiety and self-esteem between screening and pre-intervention (p values >0.24). Indeed, additional paired t-tests indicated significantly larger changes in scores between pre-intervention to post-intervention than over the baseline period for the PHQ-9 [t(22)= -3.61, p=0.002], the GAD-7 [t(22)= -4.14, p<0.001], and the RSES [t(22)= 6.38, p<0.001].
Table 5 Secondary outcome measures: Results of one-way ANOVAs, means and standard deviations and effect sizes
| Mean scores (standard deviations) | ANOVA | Effect sizes | |||||||||
| Screening | Session 1 (Pre) | Session 3 | Session 6 (Post) | Follow-up | F (df) | p-value | Pre-treatment changes (Pre – Screening) | Post – Pre | Follow-up – Pre | ||
| df | (4, 88) | ||||||||||
| Patient Health Questionnaire (PHQ-9) | 7.87
(4.07) |
8.13
(5.15) |
7.52
(4.64) |
4.87
(4.53) |
4.83
(4.54) |
7.30 | <0.001 | 0.06 | -0.63 | -0.64 | |
| Generalised Anxiety Disorder (GAD-7) | 8.78
(4.32) |
7.78
(5.08) |
7.39
(5.05) |
4.91
(4.09) |
3.83
(3.51) |
12.58 | <0.001 | -0.23 | -0.56 | -0.78 | |
| Rosenberg Self-Esteem Scale (i) | 12.22
(3.77) |
13.22
(3.95) |
13.09
(3.90) |
17.57
(3.79) |
18.48
(3.84) |
30.11
(2.26, 49.73) |
<0.001 | 0.27 | 1.10 | 1.33 | |
| df | (3, 66) | ||||||||||
| ‘Maladaptive’ perfectionism | N/A | 69.70
(14.64) |
68.13
(14.47) |
61.48
(14.30) |
56.83
(13.79) |
14.62 | <0.001 | N/A | -0.56 | -0.88 | |
Notes: (i) Greenhouse-Geisser correction applied & degrees of freedom listed in table; df: degrees of freedom
4.5.3.3 Hypothesis 3C, 4 & 5: Comparison between pre and post-intervention for process measures
In line with hypotheses, there were statistically significant improvements between pre and post-intervention and between pre-intervention and follow-up for self-compassion, beliefs about negative emotions and the ‘reappraisal’ emotion regulation strategy (p values <0.005) (see Appendix 21 for line graphs displaying mean scores for the SCS, ERQ-reappraisal, ERQ-suppression and BES at main study time points). Cohen’s d calculations indicated large effect sizes for these three process measures at post-intervention; at follow-up, the effect size for self-compassion and beliefs about negative emotions was large and the effect size for ‘reappraisal’ was medium. For self-compassion and ‘reappraisal’, there was no further significant change between post-intervention and follow-up (p values >0.09). For the BES, there was a non-significant trend for participant’s beliefs about negative emotions to continue to improve between post-intervention and follow-up (p= 0.03).
In terms of the emotion regulation strategy ‘suppression’, there was statistically significant decrease between pre and post-intervention (p= 0.003) but between pre-intervention and follow-up there was only a non-significant trend (p= 0.016).There was no significant change between post-intervention and follow-up (p= 0.71).Cohen’s d indicated a medium effect size for this emotion regulation strategy at post-intervention and follow-up.
4.5.3.4 Hypothesis 3C: Associations with reductions in self-criticism
Pearson correlations were used to determine whether reductions in self-criticism were associated with increases in self-compassion and ‘reappraisal’, and reductions in ‘suppression’ and unhelpful beliefs about emotions. For the HINT, in line with predictions, there was a strong significant negative correlation between changes in self-criticism and self-compassion [r(23)= -0.65, p= 0.001]. The correlation between changes in self-criticism and unhelpful beliefs about emotions, [r(23)= -.34, p= 0.11], ‘reappraisal’ [r(23)= -0.32, p= .13] and ‘suppression’ [r(23)= 0.24, p= .27] were non-significant.
For the SCRS, there was also a strong significant negative correlation between changes in self-criticism and changes in self-compassion [r(23)= -0.67, p<0.001]. There was a trend that changes in self-criticism correlated negatively with changes in unhelpful beliefs about emotions [r(23)= 0.50, p= 0.02] and ‘reappraisal’ [r(23)= -0.48, p= 0.02]. The correlations between changes in self-criticism and ‘suppression’ [r(23)= 0.30, p= .17] were non-significant.
Table 6 Process measures: Results of one-way ANOVAs, means and standard deviations and effect sizes
| Mean scores (standard deviations) | ANOVA | Effect sizes | ||||||
| Session 1 (Pre) | Session 3 | Session 6 (Post) | Follow-up | F (3, 66) | p-value | Post – Pre | Follow-up – Pre | |
| Self-Compassion Scale | 60.13
(12.65) |
62.13
(12.75 |
81.30
(11.75) |
85.04
(14.97) |
46.82 | <0.001 | 1.67 | 1.97 |
| Emotion Regulation Questionnaire-Reappraisal | 27.48
(6.23) |
26.91
(6.37) |
32.48
(4.79) |
32.13
(4.95) |
8.73 | <0.001 | 0.80 | 0.74 |
| Emotion Regulation Questionnaire-Suppression | 14.83
(5.56) |
13.04
(4.51) |
12.00
(5.18) |
11.70
(5.61) |
4.58 | 0.006 | -0.51 | -0.56 |
| Beliefs about Emotions Scale | 45.04
(10.98) |
41.87
(11.98) |
33.91
(12.75) |
29.78
(11.33) |
17.57 | <0.001 | -1.01 | -1.39 |
5. Discussion
This uncontrolled pilot study investigated the feasibility and acceptability of a novel intervention targeting self-criticism in a student population. Changes in self-criticism and other outcome and process measures were also investigated by comparing scores at pre-intervention with those at post-intervention and two-month follow-up.
5. 1 Hypothesis 1: Feasibility
In line with the first hypothesis that the intervention would be feasible to deliver, advertisements on the university volunteer webpage and email circular were sufficient to recruit adequate numbers of participants for the study. Retention was also good; although 6 individuals who had consented to participate in the study withdrew before starting the intervention, only 1 dropped out once the intervention had started (due to a significant life event).
The inclusion criteria of a score of at least 10 on the WASAS was successful in selecting a participant sample who reported significant distress or impairment associated with self-criticism in the screening interview and who reported at least some benefit from the intervention. This study also provides information about the mean and SD scores on measures of self-criticism that could be utilized in relation to inclusion criteria in future research studies. It should be emphasized that although these participants had a significant level of impaired functioning due to their self-criticism, they were a student sample responding to an advertisement for a research study and were not a clinical population. Thus, future research would need to assess the applicability of these cut-offs to patient populations.
In line with previous research about gender differences in psychological help-seeking (Oliver et al., 2005), the majority of participants were female. Over 50% had experienced depression in the past which suggests that it may be helpful to intervene earlier. The majority of participants were also postgraduate students, so future research could focus more on recruiting undergraduate students or even those still at school or college. Research is needed into the prevalence of high levels of self-criticism in the secondary school/college population and the feasibility and acceptability of a similar intervention for this age group.
5.2 Hypothesis 2: Acceptability
5.2.1 Acceptability of assessment methods
In line with the second hypothesis that the assessment methods would be acceptable to highly self-critical students, the telephone screening appointment was described as a helpful way to introduce individuals to the study and specific therapists. Some participants would have preferred for this appointment to have been completed face-to-face due to the sensitive nature of the questions. This may also have allowed for greater rapport from an earlier stage.Future research could assess the feasibility of face-to-face screening, taking into account challenges such as the multisite nature of the campus, room-booking issues and the extra clinician time that would be required to book in sufficiently long screening slots. It could be that other formats, for example, Skype may be an appropriate way of providing individuals with the non-verbal therapeutic cues that are less evident over the telephone, whilst still being feasible for researchers to complete.
The weekly questionnaires were completed by every participant. However, qualitative feedback suggested that some participants found the full questionnaire pack to be too lengthy to complete. This study used several measures of self-criticism; this could be reduced in future research, and fewer process measures could be included. Some participants found it burdensome to complete weekly measures. Weekly assessment had been included in case of a high level of drop-out, however, as this was not a problem, the collection of data in future studies could be reduced to pre, post and follow-up.
5.2.2 Acceptability of the intervention
In line with the second hypothesis that the intervention would be acceptable to participants, the treatment rationale was rated as logical by 90.5% of participants and 100% either “agreed” or “strongly agreed” that the intervention was useful and that they would recommend it to others. Furthermore, only one participant dropped out after starting the intervention (due to a significant life event) which is also consistent with adequate treatment acceptability. At post-intervention participant feedback indicated that the practicalities of session appointments were also acceptable; all but one participant said that there were a sufficient number of sessions, and the majority of participants (76.2%) said that no changes could be made to the intervention delivery that would have improved participation. In line with some participant feedback, future research could consider offering a choice over frequency of appointments (for example, weekly or fortnightly), or offering evening appointments.
Participants engaged well with intervention protocols both within and between sessions. On average, participants reported spending over 2 hours practicing the intervention techniques each week. On average, participants read approximately 80% of session booklets, and described these as a useful way of recapping on the session techniques. This may provide an interesting avenue for future research; ‘guided self-help’, which commonly uses written psychoeducation components, are NICE recommended for common mental health problems (NICE, 2011), thus the effectiveness of a modified form the study intervention could be assessed within the context of, for example, an Improving Access to Psychological Therapies (IAPT) service.
In terms of the specific intervention techniques, on average, all techniques were rated as at least “somewhat useful”, and the mean rating for 6 out of 8 of these was “quite a lot”. ‘Decentering’ received the highest proportion of the top usefulness rating and at follow-up 68% reported using it at least “once a week”. ‘Decentering’ is thought to enable people to distance themselves from the content of their thoughts and emotions, and gain a sense of mastery over them (Gecht et al., 2014). In line with this, the qualitative feedback suggested that participants had learnt to control their self-criticism. The ‘compassionate reframe’ was the other most popular technique; 76% gave it the first or second highest usefulness rating, which was the same proportion as for ‘decentering’. Furthermore, at follow-up, approximately 60% of participants were continuing to use this technique at least “once a week”.
Although, on average, participants rated ‘compassionate behaviours’ as “somewhat” useful at the end of the intervention, at follow-up 68% were completing these “once a week”, making this one of the three most popular technique at this time point (in addition to ‘decentering’ and ‘compassionate reframes’).It is possible that initially participants found the idea of ‘compassionate behaviours’ threatening because they may have believed that they did not deserve to do nice things for themselves, but over time felt more comfortable with it (Gilbert, 2009).
Overall, there was nothing in the participant feedback that indicated that changes to the protocol are required. However, if the intervention were to be reduced in length, the findings suggest that ‘decentering’, ‘compassionate reframes’ and ‘compassionate behaviours’ may be the most appropriate methods on which to focus.
5.3 Hypotheses 3, 4 & 5: Changes in self-criticism and other outcomes and associations between the changes
5.3.1 Impact on self-criticism and associated impairment
As predicted, there were significant reductions in self-criticism and impaired functioning from pre to post-intervention and from pre-intervention to follow-up. The intervention had a large effect size for self-criticism and a medium to large effect size for impaired functioning. Overall, these findings provide preliminary indication that the intervention may be an efficacious treatment for self-criticism. However, due to the uncontrolled nature of the study, other explanations for the reductions in self-criticism and impairment cannot be ruled out. For example, the self-criticism may have reduced anyway with the passage of time. This explanation is less likely, however, given that the average time between screening and pre-intervention was 13 weeks (i.e. longer than the time taken to complete the intervention) and the changes between screening and pre-intervention for all study measures were non-significant, with ‘negligible’ to small effect sizes, compared with medium to large effect sizes between pre-treatment and post-intervention and follow-up. Also, paired t-tests showed that there were significantly larger changes between pre-intervention and post-intervention compared with screening and pre-intervention for measures collected at both time points. Nevertheless, further research using controlled study designs would be needed to confirm these findings.
Self-criticism and functional impairment continued to decrease between end of treatment and two-month follow-up. Indeed, although only 35% of participants had moved to scores below the ‘significant functional impairment’ range on the WASAS at post-intervention, this increased to 61% at follow-up. This may have been because the additional two months had given participants more time to practice the techniques and integrate them into their day-to-day life. It is also possible that the follow-up session helped to motivate or remind participants to continue applying the techniques as they knew they would be reporting back to their therapist.
In line with the reductions on the standardised outcome measures, the participant feedback highlighted that 100% “agreed” or “strongly agreed” that the intervention was useful. However, one participant indicated “neither agree nor disagree” in relation to both the statements that the intervention had reduced their self-criticism or improved their ability to cope with self-criticism. Although this participant had not benefitted in the two key ways intended, they reported that they had learnt to view things in a more positive light.
5.3.2 Changes in secondary outcome measures
In line with hypotheses, at post-intervention participants reported lower levels of depression, anxiety and ‘maladaptive’ perfectionism and higher levels of self-esteem, and gains were maintained at follow-up. The effect sizes were medium, medium to large and large for respective outcome measures at post-intervention and follow-up. Mean levels of depression moved from the upper end of the ‘mild’ range on the PHQ-9 to the cut-off between the ‘mild’ and ‘subclinical’ range. In terms of anxiety, mean scores moved from the ‘mild’ range to the ‘sub-clinical’ range (IAPT, 2010).
Although only a minority of participants met criteria for social phobia, anecdotally, a common theme reported by individuals was self-criticism related to social situations. The CBT model of social phobia highlights the role of anticipatory and post-event processing in this disorder which can include self-critical components (Rachman, Grüter-Andrew & Shafran, 2000). It may be interesting for future research to explore further the role of self-criticism with pre and post-event cognitive processing, and whether self-compassion techniques could help deal with these components.
At pre-treatment, the mean level of self-esteem was lower than in previous research using the RSES; for example, Sinclair et al (2010) reported a mean score of 19.67 in a general population sample of people aged 18 – 25. It is therefore encouraging that participants’ mean scores increased from their much lower mean level of 12.22 to a post-intervention level that was almost the same (18.48) as that general population sample. The ‘threat/safety strategy formulation’ (Gilbert, 2010b) helped participants to identify their ‘key internal fears’ which often corresponded to negative, global, self-devaluative ‘core’ beliefs such as “I am not good enough”. It is therefore possible that the intervention helped them re-evaluate and update these with a more compassionate view of themselves.
Levels of ‘maladaptive’ perfectionism significantly reduced from pre to post-intervention, and there was a non-significant trend that participants continued to improve between post-intervention and follow-up (the effect sizes were medium at post-intervention and large at follow-up). This is not surprising as self-criticism is considered to a key component of unhealthy or ‘self-critical’ perfectionism (Dunkley, Zuroff & Blankstein, 2006). Compassionate-focused intervention may merit further investigation for students who are impaired by their perfectionism.
5.3.3 Changes in process measure
The third aim of this study was to gain preliminary information about possible mechanisms of change of the intervention. Specifically, this study focused on four possible mechanisms: self-compassion, beliefs about emotions and emotion regulation strategies (‘reappraisal’ and ‘suppression’ were measured separately).
As predicted there was a significant increase in self-compassion from pre to post-intervention with a large effect size. Furthermore, in line with hypotheses, reductions in self-criticism were associated with increases in self-compassion. This suggests that self-compassion could be investigated as a potential mediator of treatment effects in future research. These findings are consistent with the theoretical orientation of the intervention which was strongly influenced by Gilbert’s Compassionate Mind approach (2009; 2010a) and the majority of techniques were specifically focused on increasing self-compassion. The aim of Gilbert’s approach is to help participants to activate their ‘contentment-soothing-safeness system’ whilst reducing activation of their ‘threat-protection system’ (Gilbert, 2009). It is interesting to note that, at follow-up, approximately 60% of participants were completing ‘compassionate reframes’ at least “once a week” and through further discussion the majority explained that they were completing these “in their head” rather than writing down the situations. This is consistent with Gilbert’s (2009) suggestion that it is important for self-critical individuals to change their self-to-self relating (i.e. their internal dialogue with themselves) to a more compassionate stance.
However, it is important to note that one participant disagreed with the statement that the intervention had helped them to improve their self-compassion and three rated that they neither agreed nor disagreed with this statement. It is possible that these participants may have benefitted from a more intensive intervention. Alternatively, some participants may have found it more useful to have a broader focus with less emphasis on self-compassion techniques.
In terms of the emotion regulation strategy ‘reappraisal’, there was a significant increase in the use of this from pre to post-intervention, with a large effect size. There was also a non-significant trend for increases in this strategy to be correlated with reductions in self-criticism. This is consistent with the aim of the ‘compassionate reframe’ technique to facilitate a specific form of reappraisal, i.e. a more self-compassionate way of viewing the situation.
Participants reported a significant reduction in their beliefs about the unacceptability of experiencing and expressing negative emotions pre to post-intervention and pre-intervention to follow-up. There was a non-significant trend that reductions in self-criticism were associated with reductions in these unhelpful beliefs about emotions. Part of the intervention focused on the idea that self-compassion is made up of a number of ‘compassionate attributes’, including attributes about emotional expression such as distress tolerance and taking a non-judgemental acceptance towards emotions (Welford, 2012). Through these, participants were encouraged to recognize the complexity of human experience and therefore not to judge or condemn their own feelings. Participants may therefore have re-evaluated their unhelpful beliefs about emotional expression and possibly developed more compassionate beliefs about how to respond to their own distress.
In terms of ‘suppression’, there was a significant reduction between pre and post-intervention and a non-significant trend for further reduction between pre-intervention and follow-up. Similarly, to that described above, it may have been that as participants’ beliefs about negative emotions improved, they relied on the use of ‘suppression’ less. The association between changes in self-criticism and suppression was not significant, however, this may have been a power issue.
In summary, the results from this study suggest that self-compassion could be investigated further as a possible mediator of treatment outcome, although the non-significant associations between self-criticism and beliefs about emotions and emotion regulation strategies may have been related to power issues. It is likely that there were many other mechanisms of change. For example, decentering was also taught as a technique to cope with self-critical thoughts. Future research could therefore use the Experiences Questionnaire (Fresco et al., 2007) to measure decentering as an additional possible mediator.
It may also be interesting for future research to investigate other potential mechanisms, for example, the intervention may have led to increases in positive self-talk, overall self-awareness or self-acceptance or decreases in positive beliefs about self-criticism. Additionally, it is possible that more general therapeutic factors such as the strength of the therapeutic relationship, the therapist warmth and kindness, or the therapist’s ability to model the self-compassionate approach mediated the change in outcome measures; these too could be investigated further in future research.
Uncontrolled pilot studies such as the current study are limited in their ability to investigate mechanisms of change. Nevertheless a recent systematic review highlighted the need for future research to identify the ‘active’ ingredients responsible for improvements after Compassion Focused Therapy (Leaviss & Uttley, 2015). Thus, future research could explore potential mediators using a randomised controlled trial (RCT), comparing the current intervention to another treatment approach, e.g. Cognitive Behavioural Therapy. Having an active control is necessary in order to show that the study intervention specifically leads to changes in the mediator, as well as showing that the mediator changes outcome measure. Furthermore, because mediation is a causal process, future research should measure proposed mediators at time points before the outcome variable (Windgassen et al., 2016).5.4 Limitations
A key limitation of the current study is that it was an uncontrolled pilot study. It is therefore possible that improvements were due to factors other than the specific intervention. However, the baseline period prior to the intervention beginning was, on average, longer than the intervention period, and there was no significant reduction in the outcome measures between screening and pre-treatment. Secondly, the intervention consisted of multiple techniques and because no component analysis was completed, it is unclear which techniques may have been effective in bringing about change. On the other hand, participant feedback did highlight differences in the subjective usefulness of different techniques which could be used to refine the intervention for future research. Thirdly, this study had a variable baseline period (time between screening and session 1). However, the results of linear regressions suggested that this pre-intervention time variation did not account for changes in study measures. Fourthly, although the sample size was in line with what is typically viewed as sufficient for an initial pilot study, power issues are likely to have affected some of the analyses such as the correlations between outcome and process measures. The results of this study could be used to inform power calculations for future research. Finally, the study sample consisted of a small group of mainly white female student participants at one university. It is unknown to what extent these findings, including effect sizes, are generalizable to students with other characteristics, to students at other universities or to a clinical population. The current results should therefore be interpreted with caution.
5.5 Strengths
One strength of the study was the use of a two-month follow-up assessment, which provided preliminary evidence that improvements were maintained. Two therapists provided the intervention with no significant therapist differences. Furthermore, fidelity to the treatment protocol was verified by the supervisor listening to all treatment sessions. Finally, all participants completed the full set of outcome measures at every assessment point, with only a few items being missing that could be pro-rated.
5.6 Implications
This study suggests that, like other processes such as depressive rumination, presenting self-criticism as a habit that is amenable to change is acceptable for highly self-critical individuals, and that a treatment rationale based on reducing self-criticism while increasing self-compassion seemed logical. The positive results in terms of both improvements on standardised outcome measures and qualitative feedback suggests that further research, such as a larger randomised controlled trial (RCT), would be warranted. Results from the current study could be used to guide power calculations, the choice of outcome measures and potential mediators to investigate. Future research could also explore the effectiveness of the intervention in different contexts, with different populations, or using different delivery formats, such as a group or a web-based approach.
5.7 Conclusions
Self-criticism is a transdiagnostic process associated with many mental health problems and poorer outcomes in disorder-specific therapies. This is one of the first studies to target self-criticism as the main focus of an intervention. This uncontrolled pilot study assessed the feasibility and acceptability of a novel formulation-driven intervention targeting self-criticism in university students who reported distress or impairment associated with self-criticism. Multiple techniques were taught over 6-weekly sessions, the majority of which were based on Compassion Focused Therapy and therefore focused on increasing self-compassion. The intervention was found to be feasible and acceptable to participants, and intervention effect sizes ranged from medium to large at post-intervention and two-month follow-up. Secondary analyses showed statistically significant improvements across a range of outcomes which were maintained at a 2-month follow-up. Reductions in self-criticism were associated with increases in self-compassion which could be investigated as a mediator of treatment outcome. Overall, these findings suggest that a 6-session compassion-focused intervention is a promising treatment approach for self-critical university students and a larger RCT would be a promising avenue for future research.
References
Amorim P, Lecrubier Y, Weiller E, Hergueta T, Sheehan D. (1998). DSM-III-R Psychotic Disorders: procedural validity of the M.I.N.I. International Neuropsychiatric Interview (M.I.N.I.). Concordance and causes for discordance with the CIDI. European Psychiatry, 13, 26-34.
Arpin-Cribbie, C. A., Irvine, J., Ritvo, P., Cribbie, R. A., Flett, G. L., & Hewitt, P. L. (2008). Perfectionism and psychological distress: A modeling approach to understanding their therapeutic relationship. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 26(3), 151-167.
Arpin-Cribbie, C., Irvine, J., & Ritvo, P. (2012). Web-based cognitive-behavioral therapy for perfectionism: a randomized controlled trial. Psychotherapy Research, 22(2), 194-207.
Baião, R., Gilbert, P., McEwan, K., & Carvalho, S. (2015). Forms of Self‐Criticising/Attacking & Self‐Reassuring Scale: Psychometric properties and normative study. Psychology and Psychotherapy: Theory, Research and Practice, 88(4), 438-452.
Barnard, L. K. & Curry, J. F. (2011). Self-compassion: Conceptualizations, correlates, & interventions. Review of general psychology, 15, 289.
Bergman, A. J., Nyland, J. E. & Burns, L. R. (2007). Correlates with perfectionism and the utility of a dual process model. Personality and Individual Differences, 43, 389-399.
Bieling, P. J., Israeli, A. L. & Antony, M. M. (2004). Is perfectionism good, bad, or both? Examining models of the perfectionism construct. Personality and Individual Differences, 36, 1373-1385.
Blanco, C., Okuda, M., Wright, C., Hasin, D. S., Grant, B. F., Liu, S.-M. & Olfson, M. (2008). Mental health of college students and their non–college-attending peers: results from the National Epidemiologic Study on Alcohol and Related Conditions. Archives of general psychiatry, 65, 1429-1437.
Blatt, S., D’Afflitti & Quinlan, D. M. (1976). Experiences of Depression in Normal Young Adults. Journal of Abnormal Psychology, 85(4), 383 – 389.
Brackney, B. E. & Karabenick, S. A. (1995). Psychopathology and academic performance: The role of motivation and learning strategies. Journal of Counseling Psychology, 42, 456.
Castillo, L. G. & Schwartz, S. J. (2013). Introduction to the special issue on college student mental health. Journal of clinical psychology, 69, 291-297.
Cervera, S., Lahortiga, F., Angel Martínez-González, M., Gual, P., Irala-Estévez, J. D. & Alonso, Y. (2003). Neuroticism and low self-esteem as risk factors for incident eating disorders in a prospective cohort study. International Journal of Eating Disorders, 33, 271-280.
Cox, B. J., Fleet, C. & Stein, M. B. (2004). Self-criticism and social phobia in the US national comorbidity survey. Journal of Affective Disorders, 82, 227-234.
De Graaf, L. E., Roelofs, J., & Huibers, M. J. (2009). Measuring dysfunctional attitudes in the general population: the dysfunctional attitude scale (form A) revised. Cognitive therapy and research, 33(4), 345-355.
Dunkley, D. M., Zuroff, D. C., & Blankstein, K. R. (2006). Specific perfectionism components versus self-criticism in predicting maladjustment. Personality and Individual Differences, 40(4), 665-676.
Dunkley, D. M., Sanislow, C. A., Grilo, C. M. & Mcglashan, T. H. (2009). Self-criticism versus neuroticism in predicting depression and psychosocial impairment for 4 years in a clinical sample. Comprehensive psychiatry, 50, 335-346.
Eisenberg, D., Golberstein, E. & Gollust, S. E. (2007). Help-seeking and access to mental health care in a university student population. Medical care, 45, 594-601.
El Ansari, W., & Stock, C. (2011). Feeling healthy? A survey of physical and psychological wellbeing of students from seven universities in the UK. International journal of environmental research and public health, 8(5), 1308-1323.
Falconer, C. J., Slater, M., Rovira, A., King, J. A., Gilbert, P., Antley, A., & Brewin, C. R. (2014). Embodying compassion: A virtual reality paradigm for overcoming excessive self-criticism. PloS one, 9(11), e111933.
Fennell, M. J. (1998). Cognitive therapy in the treatment of low self-esteem. Advances in Psychiatric Treatment, 4, 296-304.
Fennell, M. (2013). Cognitive Therapy for Low Self-Esteem: A Transdiagnostic Perspective. Workshop Handouts for University of Bath Clinical Psychology Doctorate
Fennig, S., Hadas, A., Itzhaky, L., Roe, D., Apter, A. & Shahar, G. (2008). Self‐criticism is a key predictor of eating disorder dimensions among inpatient adolescent females. International Journal of Eating Disorders, 41, 762-765.
Fox‐Wasylyshyn, S. M., & El‐Masri, M. M. (2005). Handling missing data in self‐report measures. Research in nursing & health, 28(6), 488-495.Fresco, D. M., Moore, M. T., van Dulmen, M. H., Segal, Z. V., Ma, S. H., Teasdale, J. D., & Williams, J. M. G. (2007). Initial psychometric properties of the experiences questionnaire: validation of a self-report measure of decentering. Behavior therapy, 38(3), 234-246.
Frost, R. O., Marten, P., Lahart, C. & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive therapy and research, 14, 449-468.
Gallagher, R. (2008). National Survey of Counseling Center Directors. Available at: http://www.iacsinc.org/2008%20National%20Survey%20of%20Counseling%20Center%20Directors.pdf. Accessed on: March 1, 2016.
Gecht, J., Kessel, R., Forkmann, T., Gauggel, S., Drueke, B., Scherer, A., & Mainz, V. (2014). A mediation model of mindfulness and decentering: sequential psychological constructs or one and the same? BMC psychology, 2(1), 1.
Gilbert, P., Clarke, M., Hempel, S., Miles, J. & Irons, C. (2004). Criticizing and reassuring oneself: An exploration of forms, styles and reasons in female students. British Journal of Clinical Psychology, 43, 31-50.
Gilbert, P. (2005). Compassion: Conceptualisations, Research and Use in Psychotherapy. East Sussex: Routledge
Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment, 15, 199-208.
Gilbert, P. (2010a). An introduction to compassion focused therapy in cognitive behavior therapy. International Journal of Cognitive Therapy, 3, 97-112.
Gilbert, P. (2010b). Compassion Focused Therapy: The CBT Distinction Features Series. East Sussex: Routledge
Gilbert, P. (2010c). An Introduction to the Theory & Practice of Compassion Focused Therapy and Compassionate Mind Training for Shame Based Difficulties. Available at: http://www.compassionatemind.co.uk/downloads/training_materials/1.%20Workbook_2010.pdf
Gilbert, P., & Irons, C. (2004). A pilot exploration of the use of compassionate images in a group of self‐critical people. Memory, 12(4), 507-516.
Gilbert, P., & Irons, C. (2005). Focused therapies and compassionate mind training for shame and self‐attacking. In P. Gilbert (Ed.), Compassion: Conceptualisations, research and use in psychotherapy (pp. 263–325). London: Routledge.
Gilbert, P. & Procter, S. (2006). Compassionate mind training for people with high shame and self‐criticism: Overview and pilot study of a group therapy approach. Clinical psychology & psychotherapy, 13, 353-379.
Gross, J. J. (1998). The emerging field of emotion regulation: An integrative review. Review of General Psychology, 2, 271−299.
Gross, J. J. & John, O. P. (2003). Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85, 348.
Hertzog, M. A. (2008). Considerations in determining sample size for pilot studies. Research in nursing & health, 31(2), 180-191.
Higher Education Statistics Agency (2016, May 1). Higher Education Statistics for the United Kingdom 2012/3. Retrieved from: https://www.hesa.ac.uk/component/content/article?id=3129
Howell, D. (2012). Statistical Methods for Psychology. 8th Belmont, California: Wadsworth Publishing.
Hunt, J. & Eisenberg, D. (2010). Mental health problems and help-seeking behavior among college students. Journal of Adolescent Health, 46, 3-10.
Hurst, C. S., Baranik, L. E. & Daniel, F. (2013). College student stressors: A review of the qualitative research. Stress and Health, 29, 275-285.
Ibrahim, A. K., Kelly, S. J., Adams, C. E., & Glazebrook, C. (2013). A systematic review of studies of depression prevalence in university students. Journal of psychiatric research, 47(3), 391-400.
Improving Access to Psychological Therapies (2011). The IAPT Data Handbook: Guidance on recording and monitoring outcomes to support local evidence-based practice. National IAPT programme. Available at: http://www.iapt.nhs.uk/services/measuring-outcomes.
Iskender, M. (2009). The relationship between self-compassion, self-efficacy, and control belief about learning in Turkish university students. Social Behavior and Personality: an international journal, 37(5), 711-720.
Jazaieri, H., Jinpa, G. T., Mcgonigal, K., Rosenberg, E. L., Finkelstein, J., Simon-Thomas, E., Cullen, M., Doty, J. R., Gross, J. J. & Goldin, P. R. (2013). Enhancing compassion: A randomized controlled trial of a compassion cultivation training program. Journal of Happiness Studies, 14, 1113-1126.
Joeng, J. R., & Turner, S. L. (2015). Mediators between self-criticism and depression: Fear of compassion, self-compassion, and importance to others. Journal of counseling psychology, 62(3), 453.
Kawamura, K. Y., Hunt, S. L., Frost, R. O., & DiBartolo, P. M. (2001). Perfectionism, anxiety, and depression: Are the relationships independent? Cognitive Therapy and Research, 25(3), 291-301.
Kessler, R. C., Foster, C. L., Saunders, W. B. & Stang, P. E. (1995). Social consequences of psychiatric disorders, I: Educational attainment. American journal of psychiatry, 152, 1026-1032.
Kessler, R. C., Amminger, G. P., Aguilar‐Gaxiola, S., Alonso, J., Lee, S., & Ustun, T. B. (2007). Age of onset of mental disorders: a review of recent literature. Current opinion in psychiatry, 20(4), 359.
Kroenke, K., Spitzer, R. & Williams, J. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606-613. Leaviss, J., & Uttley, L. (2015). Psychotherapeutic benefits of compassion-focused therapy: an early systematic review. Psychological medicine,45(05), 927-945.
Lecrubier Y, Sheehan D, Weiller E, Amorim P, Bonora I, Sheehan K, Janavs J, Dunbar G. (1997). The M.I.N.I. International Neuropsychiatric Interview (M.I.N.I.) A Short Diagnostic Structured Interview: Reliability and Validity According to the CIDI. European Psychiatry, 12: 224-231.
Luyten, P., Sabbe, B., Blatt, S. J., Meganck, S., Jansen, B., De Grave, C., Maes, F. & Corveleyn, J. (2007). Dependency and self‐criticism: relationship with major depressive disorder, severity of depression, and clinical presentation. Depression and anxiety, 24, 586-596.
Macbeth, A. & Gumley, A. (2012). Exploring compassion: A meta-analysis of the association between self-compassion and psychopathology. Clinical Psychology Review, 32, 545-552.
Marshall, M. B., Zuroff, D. C., McBride, C., & Bagby, R. M. (2008). Self‐criticism predicts differential response to treatment for major depression. Journal of clinical psychology, 64(3), 231-244.
Mayhew, S. L. & Gilbert, P. (2008). Compassionate mind training with people who hear malevolent voices: A case series report. Clinical psychology & psychotherapy, 15, 113-138.
Mayring, P. (2000). Qualitative Content Analysis. Forum: Qualitative Social Research, 1(2), 20, 1-10.
Medical Outcome Systems (2016, March 1) M.I.N.I International Neuropsychiatric Interview (M.I.N.I 6.0). Retrieved from: http://www.medical-outcomes.com/index/faq
Mikolajczyk, R. T., Maxwell, A. E., Naydenova, V., Meier, S. & El Ansari, W. (2008). Depressive symptoms and perceived burdens related to being a student: Survey in three European countries. Clinical Practice and Epidemiology in Mental Health, 4, 19.
Mundt, J. C., Marks, I. M., Shear, M. K. & Greist, J. M. (2002). The Work and Social Adjustment Scale: a simple measure of impairment in functioning. The British Journal of Psychiatry, 180, 461-464.
Neff, K. (2003a). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and identity, 2, 85-101.
Neff, K. D. (2003b). The development and validation of a scale to measure self-compassion. Self and identity, 2, 223-250.
Neff, K. D. & Germer, C. K. (2013). A pilot study and randomized controlled trial of the mindful self‐compassion program. Journal of clinical psychology, 69, 28-44.
Neff, K. D., & Pommier, E. (2013). The relationship between self-compassion and other-focused concern among college undergraduates, community adults, and practicing meditators. Self and Identity, 12(2), 160-176.
NICE (2011). Common mental health problems: identification and pathways to care. NICE Clinical Guideline 123. London: National Institute for Health and Clinical Excellence.
Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of abnormal psychology, 100, 569.
Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of abnormal psychology,109(3), 504.
Nunnaly, J. C., & Bernstein, I. H. (1994). Psychometric theory. Sydney: McGraw-Hill.
O’Connor, R. C., & Noyce, R. (2008). Personality and cognitive processes: Self-criticism and different types of rumination as predictors of suicidal ideation. Behaviour Research and Therapy, 46(3), 392-401.
Oliver, M. I., Pearson, N., Coe, N., & Gunnell, D. (2005). Help-seeking behaviour in men and women with common mental health problems: cross-sectional study. The British Journal of Psychiatry, 186(4), 297-301.
Powers, T. A., Zuroff, D. C. & Topciu, R. A. (2004). Covert and overt expressions of self‐criticism and perfectionism and their relation to depression. European Journal of Personality, 18, 61-72.
Powers, T. A., Koestner, R., Zuroff, D. C., Milyavskaya, M. & Gorin, A. A. (2011). The effects of self-criticism and self-oriented perfectionism on goal pursuit. Personality and Social Psychology Bulletin, 37, 964-975.
Rachman, S., Grüter-Andrew, J., & Shafran, R. (2000). Post-event processing in social anxiety. Behaviour Research and Therapy, 38(6), 611-617.
Rector, N. A., Bagby, R. M., Segal, Z. V., Joffe, R. T., & Levitt, A. (2000). Self-criticism and dependency in depressed patients treated with cognitive therapy or pharmacotherapy. Cognitive Therapy and Research, 24(5), 571-584.
Riley, C., Lee, M., Cooper, Z., Fairburn, C. G. & Shafran, R. (2007). A randomised controlled trial of cognitive-behaviour therapy for clinical perfectionism: A preliminary study. Behaviour Research and Therapy, 45, 2221-2231.
Rimes, K.A. & Chalder, T. (2010). The Beliefs about Emotions Scale: Validity, Reliability and Sensitivity to Clinical Change. Journal of Psychosomatic Research, 68, 295-282.
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, Princeton University Press.
Rosenberg, M. (1989). Society and the adolescent self-image (rev. ed.). Middletown, CT: Wesleyan University Press.
Schanche, E. (2013). The transdiagnostic phenomenon of self-criticism.Psychotherapy, 50(3), 316.
Shafran, R., Cooper, Z., & Fairburn, C. G. (2002). Clinical perfectionism: A cognitive–behavioural analysis. Behaviour research and therapy, 40(7), 773-791.
Shafran, R., Cooper, Z., & Fairburn, C. G. (2003). “Clinical perfectionism” is not “multidimensional perfectionism”: A reply to Hewitt, Flett, Besser, Sherry & McGee. Behaviour Research and Therapy, 41(10), 1217-1220.
Shahar, B., Carlin, E. R., Engle, D. E., Hegde, J., Szepsenwol, O., & Arkowitz, H. (2012). A pilot investigation of emotion‐focused two‐chair dialogue intervention for self‐criticism. Clinical Psychology & Psychotherapy, 19(6), 496-507.
Shahar, B., Szsepsenwol, O., Zilcha‐Mano, S., Haim, N., Zamir, O., Levi‐Yeshuvi, S., & Levit‐Binnun, N. (2015). A Wait‐List Randomized Controlled Trial of Loving‐Kindness Meditation Programme for Self‐Criticism. Clinical psychology & psychotherapy, 22(4), 346-356.
Shahar, B., Doron, G., & Szepsenwol, O. (2015). Childhood Maltreatment, Shame‐Proneness and Self‐Criticism in Social Anxiety Disorder: A Sequential Mediational Model. Clinical psychology & psychotherapy, 22(6), 570-579.
Sheehan DV, Lecrubier Y, Harnett-Sheehan K, Janavs J, Weiller E, Bonara LI, Keskiner A, Schinka J, Knapp E, Sheehan MF, Dunbar GC. (1997). Reliability and Validity of the M.I.N.I. International Neuropsychiatric Interview (M.I.N.I.): According to the SCID-P. European Psychiatry, 12, 232-241.
Sheehan DV, Lecrubier Y, Harnett-Sheehan K, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar G. (1998). The M.I.N.I. International Neuropsychiatric Interview (M.I.N.I.): The Development and Validation of a Structured Diagnostic Psychiatric Interview. J. Clin Psychiatry, 59(20), 22-33.
Sinclair, S. J., Blais, M. A., Gansler, D. A., Sandberg, E., Bistis, K., & LoCicero, A. (2010). Psychometric properties of the Rosenberg Self-Esteem Scale: Overall and across demographic groups living within the United States. Evaluation & the Health Professions, 33(1), 56-80.
Smart, L. M., Peters, J. R., & Baer, R. A. (2015). Development and validation of a measure of self-critical rumination. Assessment, 1073191115573300.
Sowislo, J. F. & Orth, U. (2013). Does low self-esteem predict depression and anxiety? A meta-analysis of longitudinal studies. Psychological Bulletin, 139, 213.
Spasojević, J. & Alloy, L. B. (2001). Rumination as a common mechanism relating depressive risk factors to depression. Emotion, 1, 25.
Spitzer, R., Kroenke, K., Williams, J. & Löwe, B. (2006). A brief measure for assessing generalised anxiety disorder: the GAD-7. Archives of Internal Medicine, 166, 1092-1097.
Steele, A. L., Waite, S., Egan, S. J., Finnigan, J., Handley, A., & Wade, T. D. (2013). Psycho-education and group cognitive-behavioural therapy for clinical perfectionism: A case-series evaluation. Behavioural and cognitive psychotherapy, 41(02), 129-143.
Stumpf, H., & Parker, W. D. (2000). A hierarchical structural analysis of perfectionism and its relation to other personality characteristics. Personality and individual differences, 28(5), 837-852.
Terry, M. L., Leary, M. R., & Mehta, S. (2013). Self-compassion as a buffer against homesickness, depression, and dissatisfaction in the transition to college. Self and Identity, 12(3), 278-290.
Thabane, L., Ma, J., Chu, R., Cheng, J., Ismaila, A., Rios, L. P., Robson, R., Thabane, M., Giangregorio, L. & Goldsmith, C. H. (2010). A tutorial on pilot studies: the what, why and how. BMC medical research methodology, 10, 1.
Thompson, R., & Zuroff, D. C. (2004). The Levels of Self-Criticism Scale: comparative self-criticism and internalized self-criticism. Personality and individual differences, 36(2), 419-430.
Verplanken, B., Friborg, O., Wang, C. E., Trafimow, D. & Woolf, K. (2007). Mental habits: Metacognitive reflection on negative self-thinking. Journal of Personality and Social Psychology, 92, 526.
Waller, H., Garety, P. A., Jolley, S., Fornells-Ambrojo, M., Kuipers, E., Onwumere, J., … & Craig, T. (2013). Low intensity cognitive behavioural therapy for psychosis: a pilot study. Journal of behavior therapy and experimental psychiatry, 44(1), 98-104.
Watkins, E., Scott, J., Wingrove, J., Rimes, K., Bathurst, N., Steiner, H., Kennell–Webb, S., Moulds, M. & Malliaris, Y. (2007). Rumination-focused cognitive behaviour therapy for residual depression: A case series. Behaviour Research and Therapy, 45, 2144-2154.
Watkins, E. R., Mullan, E., Wingrove, J., Rimes, K., Steiner, H., Bathurst, N., Eastman, R. & Scott, J. (2011). Rumination-focused cognitive-behavioural therapy for residual depression: phase II randomised controlled trial. The British Journal of Psychiatry, 199, 317-322.
Weissman, A. N., & Beck, A. T. (1978). Development and validation of the Dysfunctional Attitude Scale: A preliminary investigation. Paper presented at the Annual Meeting of the American Educational Research Association, Toronto, Canada.
Welford, M. (2012). The Compassionate Mind Approach To Building Your Self-Confidence. Robinson: London.
Whelton, W. J., Paulson, B., & Marusiak, C. W. (2007). Self-criticism and the therapeutic relationship. Counselling Psychology Quarterly, 20(2), 135-148.
Williams, J. G., Stark, S. K., & Foster, E. E. (2008). Start today or the very last day? The relationships among self-compassion, motivation, and procrastination. American Journal of Psychological Research, 4, 37-44.
Windgassen, S., Goldsmith, K., Moss-Morris, R., & Chalder, T. (2016). Establishing how psychological therapies work: the importance of mediation analysis. Journal of Mental Health, 25(2), 93-99.
Appendices contents page
- Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) original approval (18.11.2014)
- Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) modification approval (27.02.2015)
- Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) modification approval (16.07.2015)
- Questionnaires completed at each time point
- Study questionnaires
- The Habitual Index of Negative Thinking
- Self-Critical Rumination Scale
- Work and Social Adjustment Scale
- Patient Health Questionnaire (PHQ-9)
- Generalised Anxiety Disorder (GAD-7)
- Rosenberg’s Self-Esteem Scale
- The Multi-Dimensional Perfectionism Scale
- Self-Compassion Scale
- The Emotion Regulation Questionnaire
- Beliefs about Emotions scale
- The Forms of Self-Criticizing/Attacking and Self-Reassuring Scale
- The Functions of Self-Criticizing/Attacking Scale
- Participant feedback questionnaire
- Measure of frequencies of use of specific intervention techniques since end of treatment collected at two-month follow-up appointment
- Online recruitment advertisement
- Participant information sheet
- Participant consent form
- Session protocols
- Blank participant formulation worksheet
- Participant booklets
- Session 1
- Session 2
- Session 3
- Session 4
- Session 5
- Post-intervention ratings of how useful participants found the intervention
- Post-intervention ratings of how useful participants found each technique
- Ratings of frequency of use for each technique since end of treatment collected at follow-up appointment
- Results of independent t-tests comparing the two therapists on participant measures across time points
- Results of linear regressions investigating relationship between (a) length of baseline (time between screening and pre-intervention), (b) time from screening to post-intervention and (c) time from pre to post intervention and change in study measures
- Line graphs for secondary outcome measures (PHQ-9, GAD-7, RSES and ‘maladaptive perfectionism) at main study time points
- Line graphs for process measures (SCS, ERQ-reappraisal, ERQ-suppression, and BES) at main study points
Appendix 1. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) original approval (18.11.2014)
| Alexandra Rose and Ruth McIntyre Department of Psychology PO78 Addiction Sciences Building Institute of Psychiatry, Psychology and Neuroscience King’s College London De Crespigny Park 20 November 2014 Dear Alexandra and Ruth, PNM/14/15-33 Self-criticism: Development of a new intervention Review Outcome: Full Approval Thank you for submitting your application for ethical approval. This was reviewed by the PNM RESC on 18 November 2014. As a result, the Committee have granted full ethical approval for your study. Provisos
You are not required to provide evidence to the Committee that these provisos have been met, but your ethical approval is only valid if these changes are made. You must not commence your research until these provisos have been met. Please ensure that you follow all relevant guidance as laid out in the King’s College London Guidelines on Good Practice in Academic Research (http://www.kcl.ac.uk/college/policyzone/index.php?id=247). For your information ethical approval is granted until 20 November 2017. If you need approval beyond this point you will need to apply for an extension to approval at least two weeks prior to this explaining why the extension is needed, (please note however that a full re-application will not be necessary unless the protocol has changed). You should also note that if your approval is for one year, you will not be sent a reminder when it is due to lapse. Ethical approval is required to cover the duration of the research study, up to the conclusion of the research. The conclusion of the research is defined as the final date or event detailed in the study description section of your approved application form (usually the end of data collection when all work with human participants will have been completed), not the completion of data analysis or publication of the results. If you do not start the project within three months of this letter please contact the Research Ethics Office. Should you wish to make a modification to the project or request an extension to approval you will need approval for this and should follow the guidance relating to modifying approved applications: http://www.kcl.ac.uk/innovation/research/support/ethics/applications/modifications.aspx Please would you also note that we may, for the purposes of audit, contact you from time to time to ascertain the status of your research. If you have any query about any aspect of this ethical approval, please contact your panel/committee administrator in the first instance (http://www.kcl.ac.uk/innovation/research/support/ethics/contact.aspx) Yours sincerely, James Patterson – Senior Research Ethics Officer For and on behalf of Professor Gareth Barker, Chairman Psychiatry, Nursing and Midwifery Research Ethics Subcommittee (PNM RESC) Cc: Katharine Rimes and Patrick Smith |
Appendix 2. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) modification approval (27.02.2015)
| Dr Ruth McIntyre and Alexandra Rose Doctoral Programme in Clinical Psychology Department of Psychology Institute of Psychiatry, Psychology and Neuroscience King’s College London 27 February 2015 Dear Ruth and Alexandra, PNM/14/15-33 Self-criticism: Development of a new intervention Thank you for submitting a modifications request for the above study. I am writing to confirm approval of these. The approved modifications are summarised broadly below:
If you have any queries, please do not hesitate to contact the Research Ethics Office. Yours sincerely, James Patterson – Senior Research Ethics Office |
Appendix 3. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) modification approval (16.07.2015)
| Alexandra Rose Doctoral Programme in Clinical Psychology Department of Psychology Institute of Psychiatry, Psychology and Neuroscience PO78 Addiction Sciences Building London SE5 8AF 16 July 2015 Dear Alexandra, PNM/14/15-33 Self-criticism: Development of a new intervention Thank you for submitting a modifications request for the above study. I am writing to confirm approval of this. The approved modification is broadly summarised below:
If you have any questions, please let me know. Yours sincerely, James Patterson – Senior Research Ethics Officer Cc: Ruth McIntyre |
Appendix 4. Questionnaires completed at each time point
| Questionnaire | Type of measure | Time point |
| The Habitual Index of Negative Thinking | Primary outcome measure | Every time point |
| Self-Critical Rumination Scale | Primary outcome measure | Every time point |
| Work and Social Adjustment Scale | Primary outcome measure | Every time point |
| Patient Health Questionnaire (PHQ-9) | Secondary outcome measure | Screening, S1, S3, S6 & follow-up |
| Generalised Anxiety Disorder (GAD-7) | Secondary outcome measure | Screening, S1, S3, S6 & follow-up |
| Rosenberg’s Self-Esteem Scale | Secondary outcome measure | Screening, S1, S3, S6 & follow-up |
| The Multi-Dimensional Perfectionism Scale | Secondary outcome measure | S1, S3, S6 & follow-up |
| Self-Compassion Scale | Process measure | S1 – S6 & follow-up |
| The Emotion Regulation Questionnaire | Process measure | S1, S3, S6 & follow-up |
| Beliefs about Emotions scale | Process measure | S1, S3, S6 & follow-up |
| The Forms of Self-Criticizing/Attacking and Self-Reassuring Scale | To aid formulation | S1 only |
| The Functions of Self-Criticizing/Attacking Scale | To aid formulation | S1 only |
Notes: S1: session 1; S3: session 3; S6: session 6
Appendix 5. Study questionnaires
- The Habitual Index of Negative Thinking
Occasionally we think about ourselves. Such thoughts may be positive, but may also be negative. In this study we are interested in negative thoughts you may have about yourself. Please indicate how much you agree or disagree with the following statements.
| 1. | Thinking negatively about myself is something…
I do frequently |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
| 2. | Thinking negatively about myself is something…
I do automatically |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
| 3. | Thinking negatively about myself is something…
I do unintentionally |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
| 4. | Thinking negatively about myself is something…
That feels sort of natural to me |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
| 5. | Thinking negatively about myself is something…
I do without further thinking |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
| 6. | Thinking negatively about myself is something…
That would require mental effort to leave |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
| 7. | Thinking negatively about myself is something…
I do every day |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
| 8. | Thinking negatively about myself is something…
I start doing before I realize I’m doing it |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
| 9. | Thinking negatively about myself is something…
I would find it hard not to do |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
| 10. | Thinking negatively about myself is something…
I do not do on purpose |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
| 11. | Thinking negatively about myself is something…
That’s typically “me” |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
| 12. | Thinking negatively about myself is something…
I have been doing for a long time |
1 | Strongly agree |
| 2 | Agree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Disagree | ||
| 5 | Strongly Disagree |
Appendix 5. Study questionnaires
- Self-Critical Rumination Scale
|
My attention is often focused on aspects of myself that I’m ashamed of | 1 | Strongly disagree |
| 2 | Disagree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Agree | ||
| 5 | Strongly agree |
| 2. | I always seem to be rehashing in my mind stupid things that I’ve said or done | 1 | Strongly disagree |
| 2 | Disagree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Agree | ||
| 5 | Strongly agree |
| 3. | Sometimes it’s hard for me to shut off critical thoughts about myself | 1 | Strongly disagree |
| 2 | Disagree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Agree | ||
| 5 | Strongly agree |
| 4. | I can’t stop thinking about how I should have acted differently in certain situations | 1 | Strongly disagree |
| 2 | Disagree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Agree | ||
| 5 | Strongly agree |
| 5. | I spend a lot of time thinking about how ashamed I am of some of my personal habits | 1 | Strongly disagree |
| 2 | Disagree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Agree | ||
| 5 | Strongly agree |
| 6. | I criticize myself a lot for how I act around other people | 1 | Strongly disagree |
| 2 | Disagree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Agree | ||
| 5 | Strongly agree |
| 7. | I wish I spent less time criticizing myself | 1 | Strongly disagree |
| 2 | Disagree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Agree | ||
| 5 | Strongly agree |
| 8. | I often worry about all of the mistakes I have made | 1 | Strongly disagree |
| 2 | Disagree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Agree | ||
| 5 | Strongly agree |
| 9. | I spend a lot of time wishing I were different | 1 | Strongly disagree |
| 2 | Disagree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Agree | ||
| 5 | Strongly agree |
| 10. | I often berate myself for not being as productive as I should be | 1 | Strongly disagree |
| 2 | Disagree | ||
| 3 | Neither agree nor disagree | ||
| 4 | Agree | ||
| 5 | Strongly agree |
Appendix 5. Study questionnaires
C. Work and Social Adjustment Scale
People’s problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity. This assessment is not intended to be a diagnosis. If you are concerned about your results in any way, please speak with a qualified health professional.
If you’re retired or choose not to have a job for reasons unrelated to your problem, tick here
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | ||||||
| Not at all | Slightly | Definitely | Markedly | Very severely | ||||||||||
| 1. | Because of my self-critical thinking my ability to work is impaired.
‘0’ means ‘not at all impaired’ and ‘8’ means very severely impaired to the point I can’t work. |
| 2. | Because of my self-critical thinking my home management (cleaning, tidying, shopping, cooking, looking after home or children, paying bills) is impaired. |
| 3. | Because of my self-critical thinking my social leisure activities (with other people e.g. parties, bars, clubs, outings, visits, dating, home entertaining) are impaired. |
| 4. | Because of my self-critical thinking my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired. |
| 5. | Because of my self-critical thinking my ability to form and maintain close relationships with others, including those I live with, is impaired. |
Appendix 5. Study questionnaires
D. Patient Health Questionnaire (PHQ-9)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
| 1. | Little interest or pleasure in doing things | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 2. | Feeling down, depressed or hopeless | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 3. | Trouble falling or staying asleep, or sleeping too much | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 4. | Feeling tired or having little energy | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 5. | Poor appetite or overeating | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 6. | Feeling bad about yourself – or that you are a failure or have let yourself or your family down | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 7. | Trouble concentrating on things, such as reading the newspaper or watching television | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 8. | Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 9. | Thoughts that you would be better off dead, or hurting yourself | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
Appendix 5. Study questionnaires
E. Generalised Anxiety Disorder (GAD-7)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
| 1. | Feeling nervous, anxious or on edge | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 2. | Not being able to stop or control worrying | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 3. | Worrying too much about different things | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 4. | Trouble relaxing | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 5. | Being so restless that it is hard to sit still | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 6. | Becoming easily annoyed or irritable | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
| 7. | Feeling afraid as if something awful might happen | 0 | Not at all |
| 1 | Several days | ||
| 2 | More than half the days | ||
| 3 | Nearly every day |
Appendix 5. Study questionnaires
F. Rosenberg’s Self-Esteem Scale
Below is a list of statements dealing with your general feelings about yourself. If you strongly agree, circle 1. If you agree with the statement, circle 2. If you disagree, circle 3. If you strongly disagree, circle 4.
| 1. | I feel that I’m a person of worth, at least on an equal plane with others. | 1 | Strongly agree |
| 2 | Agree | ||
| 3 | Disagree | ||
| 4 | Strongly Disagree |
| 2. | I feel that I have a number of good qualities. | 1 | Strongly agree |
| 2 | Agree | ||
| 3 | Disagree | ||
| 4 | Strongly Disagree |
| 3. | All in all, I am inclined to feel that I am a failure. | 1 | Strongly agree |
| 2 | Agree | ||
| 3 | Disagree | ||
| 4 | Strongly Disagree |
| 4. | I am able to do things as well as most other people. | 1 | Strongly agree |
| 2 | Agree | ||
| 3 | Disagree | ||
| 4 | Strongly Disagree |
| 5. | I feel I do not have much to be proud of. | 1 | Strongly agree |
| 2 | Agree | ||
| 3 | Disagree | ||
| 4 | Strongly Disagree |
| 6. | I take a positive attitude toward myself. | 1 | Strongly agree |
| 2 | Agree | ||
| 3 | Disagree | ||
| 4 | Strongly Disagree |
| 7. | On the whole, I am satisfied with myself. | 1 | Strongly agree |
| 2 | Agree | ||
| 3 | Disagree | ||
| 4 | Strongly Disagree |
| 8. | I wish I could have more respect for myself. | 1 | Strongly agree |
| 2 | Agree | ||
| 3 | Disagree | ||
| 4 | Strongly Disagree |
| 9. | I certainly feel useless at times. | 1 | Strongly agree |
| 2 | Agree | ||
| 3 | Disagree | ||
| 4 | Strongly Disagree |
| 10 | At times, I think I am no good at all. | 1 | Strongly agree |
| 2 | Agree | ||
| 3 | Disagree | ||
| 4 | Strongly Disagree |
Appendix 5. Study questionnaires
G. The Multi-Dimensional Perfectionism Scale
| Please circle the number that best corresponds to your agreement with each statement below. Please rate how you feel now. | Strongly Strongly disagree agree | ||||
| 1. My parents set very high standards for me. | 1 | 2 | 3 | 4 | 5 |
| 2. Organisation is very important to me. | 1 | 2 | 3 | 4 | 5 |
| 3. As a child, I was punished for doing things less than perfectly. | 1 | 2 | 3 | 4 | 5 |
| If I do not set the highest standards for myself, I am likely to end up a second-rate person. | 1 | 2 | 3 | 4 | 5 |
| 5. My parents never tried to understand my mistakes. | 1 | 2 | 3 | 4 | 5 |
| 6. It is important to me that I be thoroughly competent in everything I do. | 1 | 2 | 3 | 4 | 5 |
| 7. I am a neat person. | 1 | 2 | 3 | 4 | 5 |
| 8. I try to be an organised person. | 1 | 2 | 3 | 4 | 5 |
| 9. If I fail at work / school, I am a failure as a person. | 1 | 2 | 3 | 4 | 5 |
| 10. I should be upset if I make a mistake. | 1 | 2 | 3 | 4 | 5 |
| 11. My parents wanted me to be the best at everything. | 1 | 2 | 3 | 4 | 5 |
| 12. I set higher goals than most people. | 1 | 2 | 3 | 4 | 5 |
| If someone does a task at work / school better than I, then I feel like I failed the whole task. | 1 | 2 | 3 | 4 | 5 |
| 14. If I fail partly, it is as bad as being a complete failure. | 1 | 2 | 3 | 4 | 5 |
| Only outstanding performance is good enough in my family. | 1 | 2 | 3 | 4 | 5 |
| 16. I am very good at focusing my efforts on attaining a goal. | 1 | 2 | 3 | 4 | 5 |
| Even when I do something very carefully, I often feel that it is not quite right. | 1 | 2 | 3 | 4 | 5 |
| 18. I hate being less than best at things. | 1 | 2 | 3 | 4 | 5 |
| 19. I have extremely high goals. | 1 | 2 | 3 | 4 | 5 |
| 20. My parents have expected excellence from me. | 1 | 2 | 3 | 4 | 5 |
| 21. People will probably think less of me if I make a mistake. | 1 | 2 | 3 | 4 | 5 |
| 22. I never felt like I could meet my parents’ expectations. | 1 | 2 | 3 | 4 | 5 |
| 23. If I do not do as well as other people, it means I am an inferior
human being. |
1 | 2 | 3 | 4 | 5 |
| 24. Other people seem to accept lower standards from themselves than I do. | 1 | 2 | 3 | 4 | 5 |
| 25. If I do not do well all the time, people will not respect me. | 1 | 2 | 3 | 4 | 5 |
| 26. My parents have always had higher expectations for my future than
I have. |
1 | 2 | 3 | 4 | 5 |
| 27. I try to be a neat person. | 1 | 2 | 3 | 4 | 5 |
| 28. I usually have doubts about the simple everyday things I do. | 1 | 2 | 3 | 4 | 5 |
| 29. Neatness is very important to me. | 1 | 2 | 3 | 4 | 5 |
| 30. I expect higher performance in my daily tasks than most people. | 1 | 2 | 3 | 4 | 5 |
| 31. I am an organised person. | 1 | 2 | 3 | 4 | 5 |
| 32. I tend to get behind in my work because I repeat things over and over. | 1 | 2 | 3 | 4 | 5 |
| 33. It takes me a long time to do something ‘right’. | 1 | 2 | 3 | 4 | 5 |
| 34. The fewer mistakes I make, the more people will like me. | 1 | 2 | 3 | 4 | 5 |
| 35. I never felt like I could meet my parents’ standards. | 1 | 2 | 3 | 4 | 5 |
Appendix 5. Study questionnaires
H. Self-Compassion Scale
HOW I TYPICALLY ACT TOWARDS MYSELF IN DIFFICULT TIMES
Please read each statement carefully before answering. To the left of each item, indicate how often you behave in the stated manner, using the following scale:
Almost never Almost always
1 2 3 4 5
_____ 1. I’m disapproving and judgmental about my own flaws and inadequacies.
_____ 2. When I’m feeling down I tend to obsess and fixate on everything that’s wrong.
_____ 3. When things are going badly for me, I see the difficulties as part of life that everyone goes through.
_____ 4. When I think about my inadequacies, it tends to make me feel more separate and cut off from the rest of the world.
_____ 5. I try to be loving towards myself when I’m feeling emotional pain.
_____ 6. When I fail at something important to me I become consumed by feelings of inadequacy.
_____ 7. When I’m down and out, I remind myself that there are lots of other people in the world feeling like I am.
_____ 8. When times are really difficult, I tend to be tough on myself.
_____ 9. When something upsets me I try to keep my emotions in balance.
_____ 10. When I feel inadequate in some way, I try to remind myself that feelings of inadequacy are shared by most people.
_____ 11. I’m intolerant and impatient towards those aspects of my personality I don’t like.
_____ 12. When I’m going through a very hard time, I give myself the caring and tenderness I need.
_____ 13. When I’m feeling down, I tend to feel like most other people are probably happier than I am.
_____ 14. When something painful happens I try to take a balanced view of the situation.
_____ 15. I try to see my failings as part of the human condition.
_____ 16. When I see aspects of myself that I don’t like, I get down on myself.
_____ 17. When I fail at something important to me I try to keep things in perspective.
_____ 18. When I’m really struggling, I tend to feel like other people must be having an easier time of it.
_____ 19. I’m kind to myself when I’m experiencing suffering.
_____ 20. When something upsets me I get carried away with my feelings.
_____ 21. I can be a bit cold-hearted towards myself when I’m experiencing suffering.
_____ 22. When I’m feeling down I try to approach my feelings with curiosity and openness.
_____ 23. I’m tolerant of my own flaws and inadequacies.
_____ 24. When something painful happens I tend to blow the incident out of proportion.
_____ 25. When I fail at something that’s important to me, I tend to feel alone in my failure.
_____ 26. I try to be understanding and patient towards those aspects of my personality I don’t like.
Appendix 5. Study questionnaires
I. The Emotion Regulation Questionnaire
We would like to ask you some questions about your emotional life, in particular, how you control (that is, regulate and manage) your emotions. The questions below involve two distinct aspects of your emotional life. One is your emotional experience, or what you feel like inside. The other is your emotional expression, or how you show your emotions in the way you talk, gesture, or behave. Although some of the following questions may seem similar to one another, they differ in important ways. For each item, please answer using the following scale:
1—————–2——————3——————4——————5——————6——————7
strongly neutral strongly
disagree agree
| Rating (0-7) | |
| 1. When I want to feel more positive emotion (such as joy or amusement), I change what I’m thinking about. | |
| 2. I keep my emotions to myself. | |
| 3. When I want to feel less negative emotion (such as sadness or anger), I change what I’m thinking about. | |
| 4. When I am feeling positive emotions, I am careful not to express them. | |
| 5. When I’m faced with a stressful situation, I make myself think about it in a way that helps me stay calm. | |
| 6. I control my emotions by not expressing them. | |
| 7. When I want to feel more positive emotion, I change the way I’m thinking about the situation. | |
| 8. I control my emotions by changing the way I think about the situation I’m in. | |
| 9. When I am feeling negative emotions, I make sure not to express them. | |
| 10. When I want to feel less negative emotion, I change the way I’m thinking about the situation. |
Appendix 5. Study questionnaires
J. Beliefs about Emotions scale
Please tick the column that best describes how you think. Please note that because people are different, there are no right or wrong answers to these statements. To decide whether a given answer is typical of your way of looking at things, simply keep in mind how you think most of the time.
| Totally agree | Agree very much | Agree slightly | Neutral | Disagree slightly | Disagree very much | Totally disagree | |
| It is a sign of weakness if I have miserable thoughts. | |||||||
| If I have difficulties I should not admit them to others. | |||||||
| If I lose control of my emotions in front of others, they will think less of me. | |||||||
| I should be able to control my emotions. | |||||||
| If I am having difficulties it is important to put on a brave face. | |||||||
| If I show signs of weakness then others will reject me. | |||||||
| I should not let myself give in to negative feelings. | |||||||
| I should be able to cope with difficulties on my own without turning to others for support. | |||||||
| To be acceptable to others, I must keep any difficulties or negative feelings to myself. | |||||||
| It is stupid to have miserable thoughts. | |||||||
| It would be a sign of weakness to show my emotions in public. | |||||||
| Others expect me to always be in control of my emotions. |
Appendix 5. Study questionnaires
K. The Forms of Self-Criticizing/Attacking and Self-Reassuring Scale
When things go wrong in our lives or don’t work out as we hoped, and we feel we could have done better, we sometimes have negative and self-critical thoughts and feelings. These may take the form of feeling worthless, useless or inferior etc. However, people can also try to be supportive of them selves. Below are a series of thoughts and feelings that people sometimes have. Read each statement carefully and circle the number that best describes how much each statement is true for you.
Please use the scale below.
| 1. | When things go wrong for me…
I am easily disappointed with myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 2. | When things go wrong for me…
There is a part of me that puts me down |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 3. | When things go wrong for me…
I am able to remind myself of positive things about myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 4. | When things go wrong for me…
I find it difficult to control my anger and frustration at myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 5. | When things go wrong for me…
I find it easy to forgive myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 6. | When things go wrong for me…
There is a part of me that feels I am not good enough |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 7. | When things go wrong for me…
I feel beaten down by my own self-critical thoughts |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 8. | When things go wrong for me…
I still like being me |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 9. | When things go wrong for me…
I have become so angry with myself that I want to hurt or injure myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 10. | When things go wrong for me…
I have a sense of disgust with myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 11. | When things go wrong for me…
I can still feel loveable and acceptable |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 12. | When things go wrong for me…
I stop caring about myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 13. | When things go wrong for me…
I find it easy to like myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 14. | When things go wrong for me…
I remember and dwell on my failings |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 15. | When things go wrong for me…
I call myself names |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 16. | When things go wrong for me…
I am gentle and supportive with myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 17. | When things go wrong for me…
I can’t accept failures and setbacks without feeling inadequate |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 18. | When things go wrong for me…
I think I deserve me self-criticism |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 19. | When things go wrong for me…
I am able to care and look after myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 20. | When things go wrong for me…
There is a part of me that wants to get rid of the bits I don’t like |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 21. | When things go wrong for me…
I encourage myself for the future |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 22. | When things go wrong for me…
I do not like being me |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
Appendix 5. Study questionnaires
L. The Functions of Self-Criticizing/Attacking Scale
There can be many reasons why people become critical and angry with themselves. Read each statement carefully and circle the number that best describes how much each statement is true for you.
Use the scale below.
| 1. | I get critical and angry with myself…
To make sure I keep up my standards |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 2. | I get critical and angry with myself…
To stop myself being happy |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 3. | I get critical and angry with myself…
To show I care about my mistakes |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 4. | I get critical and angry with myself…
Because if I punish myself I feel better |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 5. | I get critical and angry with myself…
To stop me being lazy |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 6. | I get critical and angry with myself…
To harm part of myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 7. | I get critical and angry with myself…
To keep myself in check |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 8. | I get critical and angry with myself…
To punish myself for my mistakes |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 9. | I get critical and angry with myself…
To cope with feelings of disgust with myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 10. | I get critical and angry with myself…
To take revenge on part of myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 11. | I get critical and angry with myself…
To stop my getting overconfident |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 12. | I get critical and angry with myself…
To stop me being angry at others |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 13. | I get critical and angry with myself…
To destroy a part of me |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 14. | I get critical and angry with myself…
To make me concentrate |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 15. | I get critical and angry with myself…
To gain reassurance from others |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 16. | I get critical and angry with myself…
To stop me becoming arrogant |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 17. | I get critical and angry with myself…
To prevent future embarrassments |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 18. | I get critical and angry with myself…
To remind me of my past failures |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 19. | I get critical and angry with myself…
To keep me from making minor mistakes |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 20. | I get critical and angry with myself…
To remind me of my responsibilities |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
| 21. | I get critical and angry with myself…
To get at the things I hate in myself |
0 | Not at all like me |
| 1 | A little bit like me | ||
| 2 | Moderately like me | ||
| 3 | Quite a bit like me | ||
| 4 | Extremely like me |
If you can think of any other reasons why you become self-critical please write them in the space below:
……………………………………………………………………………………………………………………………………………………
Leave a Reply