Compassion Focused Therapy Intervention to Reduce Self-criticism

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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 4 Primary outcome measures: Results of one-way ANOVAs, means and standard deviations and effect sizes

Table 5 Secondary outcome measures: Results of one-way ANOVAs, means and standard deviations and effect sizes

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

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)

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:

  1. To assess the acceptability and feasibility of the new intervention and assessment methods to investigate the impact of this intervention.
  2. 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.
  3. 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:

  1. The intervention would be feasible to deliver in terms of the recruitment and retention;
  2. Participants would find both the intervention and assessment methods acceptable;
  3. At post-treatment compared to baseline participants would report:
    1. Lower levels of self-criticism and associated impairments in functioning;
    2. Lower levels of depression, anxiety and ‘maladaptive’ perfectionism and higher levels of self-esteem;
    3. 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.
  4. There would be significantly larger improvements in key outcomes from pre-treatment to post-treatment than between screening and pre-treatment assessments.
  5. 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

  1. Completing a KCL university course;
  2. Aged at least 18 years old;
  3. A high score on a self-criticism measure;
  4. Self-criticism is causing significant impairment in educational, social or other important areas of functioning as indicated by a score of 10 or above on the Work and Social Adjustment Scale (Mundt et al., 2002);
  5. Sufficient proficiency in English language;
  6. Access to a GP and be willing to provide contact details and agree that they could be contacted if there were risk or safety concerns;
  7. If taking anti-depressants, on a stable dose for at least 3 months (medication use was also checked at post-treatment at follow-up).

Exclusion Criteria

  1. Current suicidal or self-harming thoughts or behaviours to a level requiring formal mental health service assistance;
  2. Meets DSM-IV criteria for a psychotic disorder or substance dependence;
  3. Meets DSM-IV or DSM-V criteria for anorexia nervosa;
  4. Currently receiving another psychological intervention;
  5. Currently experiencing a degree of life stress or on-going psychological issues that are judged to adversely affect their ability to benefit from the intervention;
  6. A disorder that is likely to impair capacity to give informed consent.

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?
  • Recruitment/enrolment rates of eligible participants across recruitment drives
Is the inclusion/exclusion criteria appropriate for the target population?
  • Modifications to inclusion/exclusion criteria
Retention Do participants complete the intervention? Number of drop outs:

  1. Pre-intervention
  2. During intervention
  3. At follow-up

 

Table 2 Acceptability of assessment methods and intervention

Objective Specific Objective Outcome
Assessment methods How acceptable are the:

  • Telephone screening
  • Weekly self-report questionnaires
  • Qualitative feedback
  • Completion rates of questionnaires
Intervention How acceptable is the intervention content?

 

  • Participant ratings of how ‘logical’ intervention approach seemed to be
  • Quantitative and qualitative feedback about usefulness of intervention, including session booklets
  • Adherence to/acceptability of specific techniques
  • Time spent practicing each week
  • Quantitative ratings about usefulness of techniques
  • Frequency ratings of use of techniques at follow-up
How acceptable are the practical aspects of the sessions?
  • Number of participants who attend sessions
  • Qualitative feedback

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.

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Appendices contents page

  1. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) original approval (18.11.2014)
  2. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) modification approval (27.02.2015)
  3. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) modification approval (16.07.2015)
  4. Questionnaires completed at each time point
  5. Study questionnaires
    1. The Habitual Index of Negative Thinking
    2. Self-Critical Rumination Scale
    3. Work and Social Adjustment Scale
    4. Patient Health Questionnaire (PHQ-9)
    5. Generalised Anxiety Disorder (GAD-7)
    6. Rosenberg’s Self-Esteem Scale
    7. The Multi-Dimensional Perfectionism Scale
    8. Self-Compassion Scale
    9. The Emotion Regulation Questionnaire
    10. Beliefs about Emotions scale
    11. The Forms of Self-Criticizing/Attacking and Self-Reassuring Scale
    12. The Functions of Self-Criticizing/Attacking Scale
  6. Participant feedback questionnaire
  7. Measure of frequencies of use of specific intervention techniques since end of treatment collected at two-month follow-up appointment
  8. Online recruitment advertisement
  9. Participant information sheet
  10. Participant consent form
  11. Session protocols
  12. Blank participant formulation worksheet
  13. Participant booklets
    1. Session 1
    2. Session 2
    3. Session 3
    4. Session 4
    5. Session 5
  14. Post-intervention ratings of how useful participants found the intervention
  15. Post-intervention ratings of how useful participants found each technique
  16. Ratings of frequency of use for each technique since end of treatment collected at follow-up appointment
  17. Results of independent t-tests comparing the two therapists on participant measures across time points
  18. 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
  19. Line graphs for secondary outcome measures (PHQ-9, GAD-7, RSES and ‘maladaptive perfectionism) at main study time points
  20. 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
London SE5 8AF

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
Your approval is based on the following provisos being met:

  1. Sections 2.2 and 2.3: Please note that ethical approval for doctoral studies is normally granted for a period of 3 years.
  2. Section 7.1:
  1. The recruitment documents should clearly indicate that the study is a research project.  There, the Committee strongly recommends that paragraphs beginning with ‘We are offering…’ are reworded to reflect this.
  2. The Committee recommends that participants are allowed at least 24 hours to consider whether to take part after reading the Information Sheet.
  1. Information Sheet:
  1. Remove the paragraph entitled ‘What if there is a problem?’
  2. Insert the paragraph beginning with ‘If this study has harmed you in any way…’ before the contact details for your academic supervisors.

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.
For projects that only involve the further analysis of pre-existing data, approval must cover any period during which the researcher will be accessing or evaluating individual sensitive and/or un-anonymised records.
Note that after the point at which ethical approval for your study is no longer required due to the study being complete (as per the above definitions), you will still need to ensure all research data/records management and storage procedures agreed to as part of your application are adhered to and carried out accordingly.

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)
We wish you every success with this work.

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
PO78, Addiction Sciences Building
London SE5 8AF

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:

  1. Section 4:
  1. Collection of GAD-7, PHQ-9 and Rosenberg’s Self-Esteem Scale measures at T1.
  2. Use of SurveyMonkey to collect responses to measures T1 to T5.
  1. Section 6.2: Addition of anorexia nervosa to the exclusion criteria.
  2. Section 6.3: Use of Mini International Neuropsychiatric Interview for screening

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:

  1. Section 4: Collection of data about participants’ ethnicity during screening.

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

  1. 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

  1. Self-Critical Rumination Scale
  1. 1.
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:

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Appendix 6. Participant feedback questionnaire

Question Type of response Scoring
  1. Please enter your participant number
Open-ended
  1. Overall, how much of the weekly booklets did you read (approximately)? Please indicate a percentage
Options: 0; 10; 20; 30; 40; 50; 60; 70; 80; 90; 100%
  1. On average how much time did you spend doing the homework tasks?
Open-ended
  1. How useful did you find each technique?
    1. Compassionate reframe/thought record
    2. Decentering from self-critical thoughts
    3. Changing the context of the self-criticism
    4. Relaxation exercises
    5. Compassionate other imagery
    6. Loving-kindness meditation
    7. The Compassionate self (imagining your compassionate self and/or guiding your day with self-compassion
    8. Compassionate behaviours
Options: Not at all; a little; somewhat; quite a lot; very much; N/A – didn’t try at all Not at all = 0; a little = 1; somewhat = 2; quite a lot = 3; very much = 4
  1. What are the most important things that you have gained or learnt during the intervention, if anything?
Open-ended
  1. Is there anything we could have changed (time/ location/ duration/ frequency/format e.g. group, telephone, skype etc) that would have made it easier for you to participate in/ attend the sessions?
Open-ended
  1. Please comment on anything else that you found helpful or unhelpful with the following aspects of the intervention:
    1. The initial telephone screening
    2. The practical arrangements of the sessions
    3. The length, content or structure of the sessions
    4. The number of sessions
    5. The booklets
    6. The collection of questionnaires each week on survey monkey
    7. Your interactions with your facilitator
Open-ended
  1. The intervention was useful
Options: Strongly disagree; Disagree; Neither agree or disagree; Agree; Strongly agree Strongly disagree = 1; Disagree =2; Neither agree or disagree = 3; Agree = 4; Strongly agree = 5
  1. The intervention helped to reduce my self-critical thinking
Options: Strongly disagree; Disagree; Neither agree or disagree; Agree; Strongly agree As above
  1. The intervention helped improve my ability to cope with my self-critical thinking
Options: Strongly disagree; Disagree; Neither agree or disagree; Agree; Strongly agree As above
  1. My facilitator understood my needs/ difficulties
Options: Strongly disagree; Disagree; Neither agree or disagree; Agree; Strongly agree As above
  1. I would recommend the intervention to other people with high levels of self-criticism
Options: Strongly disagree; Disagree; Neither agree or disagree; Agree; Strongly agree As above
  1. Any other comments?
Open-ended

Appendix 7. Measure of frequencies of use of specific intervention techniques since end of treatment collected at two-month follow-up appointment

  Not at all Once or twice Several times Once a week Several times a week Every day
Scoring 0 1 2 3 4 5
Compassionate reframe            
Decentring            
Changing the context            
Abdominal breathing            
Progressive muscle relaxation            
Compassionate other imagery            
Compassionate self imagery            
Guiding your day with self-compassion            
Loving-kindness meditation            
Compassionate behaviours            

Appendix 8. Flow chart to show participants’ journey and involvement of therapists

Interested individuals responded to online advertisement

Email response with link to screening questionnaires sent by Therapist 1

Interested individuals completed screening questionnaires

Therapist 1 (n=34) & Therapist 2 (n=34) contacted those who completed questionnaires to either offer screening or signpost to alternative sources of support

Therapist 1 (n=24) & Therapist 2 (n=23) completed telephone screening to assess eligibility

Telephone screenings discussed with study supervisor

Individuals informed of decision through email or telephone contact

Eligible individuals who wished to take part completed Participant Consent Form and received treatment straight away or put on waiting list

Started treatment with either Therapist 1 or Therapist 2

Therapist 2

n=12

n=12

Participants completed weekly questionnaires and face-to-face appointments across 5 weeks

n=11

n=12

Participants completed online questionnaires 2-months post-intervention

n=12

n=11

Participants attended 2-month telephone follow-up appointment

n=10

n=12

Therapist 1 (author)

First face-to-face appointment: Qualitative interview for analysis by therapist 2 for her thesis, followed by Session 1 of intervention for current study

Qualitative analysis for thesis of therapist 2 (n=24)

Feasibility, acceptability & quantitative pre and post outcome data (n=23)

Analysis of

Appendix 9. Online recruitment advertisement

Self-criticism: Development of a new intervention

Advertisement for use for recruitment of volunteers for study ref: [PNM/14/15-33], approved by the Psychiatry, Nursing and Midwifery Research Ethics Sub-Committee (PNM RESC). This project contributes to the College’s role in conducting research, and teaching research methods. You are under no obligation to reply to this email, however if you choose to, participation in this research is voluntary and you may withdraw at any time.

ARE YOU VERY SELF-CRITICAL?

  • Do you notice lots of self-critical thoughts?
  • Do you become easily disappointed with yourself?
  • When you make mistakes are you very hard on yourself?
  • Do you go over the things you don’t like about yourself in your head?
  • Do you find it difficult to control your self-critical thoughts?

 

  • Would you like to take part in research into a new method aimed at reducing unhelpful self-criticism?

 

We are carrying out a research study, where you could be invited to take part in an interview/assessment plus 5 individual sessions to help you develop strategies to reduce self-critical thinking. The first session will last 1-2 hours and subsequent sessions will take 1 hour. The sessions will take place on a weekly basis, unless you would prefer otherwise. We plan for the sessions to be held at the Denmark Hill, the Strand or Guy’s campus of King’s College London, however, alternative arrangements may be possible depending on what is convenient for you.  In order to check whether you are suitable for the study, you would be asked to complete some questionnaires and talk to one of us on the telephone.

You could be eligible to take part in our study, if you:

  • Feel that your self-criticism is causing you significant distress or causing you problems in one or more areas of your life, including work, studying, relationships or body image.
  • Are an undergraduate or postgraduate student.

For further information about the study (with no obligation to take part), please contact alexandra rose ([email protected]) or ruth mcintyre ([email protected]).

 

 

KCL logo without UoL strapline

Appendix 10. Participant information sheet

INFORMATION SHEET FOR PARTICIPANTS

 

YOU WILL BE GIVEN A COPY OF THIS INFORMATION SHEET

 

Self-criticism: Development of a new intervention

We would like to invite you to participate in this postgraduate research project. You should only participate if you want to; choosing not to take part will not disadvantage you in any way. Before you decide whether you want to take part, it is important for you to understand why the research is being done and what your participation will involve. Please take time to read the following information carefully and discuss it with others if you wish. Ask us if there is anything that is not clear or if you would like more information.

What is the purpose of this study?

This study is investigating a new intervention for students who are looking for help to reduce their self-critical thinking. This study is part of a doctoral research project. This study is being conducted by Alexandra Rose and Ruth McIntyre, clinical psychologists in training at the Institute of Psychiatry, Psychology and Neuroscience, together with Dr Katharine Rimes and Dr Patrick Smith, honorary consultant clinical psychologists and senior lecturers at King’s College London.

 

Why have I been invited to take part?

We are recruiting KCL undergraduate and postgraduate students who have respondent to advertisements for the study.

 

Am I eligible to take part?

You may be eligible to take part if you tend to be self-critical and you want help to reduce this, because it causes you distress or other problems. This will be assessed by your scores on questionnaires and a discussion with one of the researchers over the telephone.

Self-criticism can affect various different areas of our lives including work, studying and relationships. Participants must be aged at least 18 years of age and be an undergraduate or postgraduate student at KCL. There are certain reasons why people may not be suitable. This includes having current problems that would interfere with one’s ability to benefit from such help, for example, substance dependence and anorexia nervosa. If you are not eligible to take part in the study the researcher will explain this to you at the time of the telephone screening.

If you take part in this study you would need to be available to take part in an in-depth interview and 5 individual sessions.

 

Do I have to take part?

It is up to you whether or not you take part. If you do decide to take part, you will be asked to sign a consent form. Having signed the consent form, you are still free to withdraw your participation without giving a reason, up until the point the data has been analysed. For information from your interview, this will be a month after the interview, whereas the questionnaire data can be withdrawn up until December 2015. A decision to withdraw, or a decision not to take part, will not affect any other care that you may receive, such as through the NHS or the student support services.

 

What will happen to me if I take part?

The first thing you will be asked to do will be to take part in a brief telephone screening; prior to the telephone call you will be emailed a link to complete some brief questionnaires about your style of thinking and the impact this has on your life. The purpose of this is to determine whether this intervention would be helpful for you. Your answers to these questionnaires will be scored and based on this you will be invited to take part in the intervention.  During the telephone screening you will have the opportunity to ask any questions that you might have about the project.  We will also ask for you to provide your GP details. Your GP will only be contacted if the clinicians feel concerned that there is a risk to your safety or the safety of other people. The brief telephone screening may take up to 45 minutes.

Once you are invited to take part in the intervention, you will be asked to sign and return the consent form. Prior to the first session you will be emailed a link to a set of questions, which you will be asked to complete in your own time.  During the first session you come to you will be asked a number of questions about your experiences of self-criticism. This will help to inform subsequent sessions. The content of this session will be audio-recorded and transcribed onto a password-protected computer. It will also be anonymised and combined with other people’s responses to help us better understand the experience of self-criticism. The focus of the five subsequent sessions will be on developing strategies to better manage your self-critical thoughts drawing on techniques from self-compassion training. These sessions will also be audio-recorded. You will also be asked to complete a series of questionnaires at different time-points during the intervention, including mid-way, at the end and two months after the intervention.

 

New intervention to reduce self-criticism

The help provided will take your preferences into account and will draw on elements of cognitive behaviour therapy and self-compassion training.

Being self-compassionate means adopting the qualities of kindness, warmth, strength and non-judgement and directing them towards the self. Self-compassion is a skill that we can develop further.

You will be taught a range of exercises and strategies to reduce your self-critical thinking and increase your self-compassion. These sessions will help you to become aware of and to understand why your self-criticism has developed. You will be given information about the benefits of self-compassion.

The benefit of having individual sessions is that the intervention will be targeted to suit your individual needs. You will also be able to troubleshoot any difficulties you may encounter in a safe and confidential space. You will only be encouraged to use methods that feel ok for you. As this is a new intervention we are keen to receive feedback at all stages.

 

Data and audio-recording

In order to be able to analyse the data from the study, we will ask for your consent for members of the research team to have access to your questionnaire responses. All of your completed questionnaire responses will be anonymised by labelling them with a number rather than with your name. They will be stored securely at Kings College London. We will also ask your permission to audio record the sessions, for supervision purposes and so that we can check that the sessions were being run according to the research protocol.  The audio-recording of the first interview session will be transcribed and stored electronically on a password-protected computer. All audio-recordings will be deleted once they have been transcribed or used for supervision purposes. Interview content will be analysed to identify any common themes that emerge. In reporting the findings, quotes may be used, however, these written/spoken reports will not contain any identifying information about those who take part.

 

Confidentiality – who will know that I am taking part in this study?

All information relating to you participating in this study will be securely stored, either on a password-protected computer at King’s College London, or locked in a filing cabinet. No completed questionnaires will be labelled using your name or any other identifiable information. Instead, each questionnaire will be labelled with a unique identification number. The only people who will have access to your data from the study will be the research team.

 

Other forms of help for self-criticism

We ask that you do not have any other form of help (e.g. counselling) for your self-criticism during the time that you are attending the intervention sessions, otherwise we will not be able to tell whether there has been any impact of the help that we have provided. If you take part, you can continue taking any medication. If you are taking antidepressant medication, you need to have been on a stable dose for at least three months before starting this study.

You are free to choose not to participate in this research trial. If you do not want to participate in the trial, you will continue to be able to seek other available help.

 

What are the possible risks or disadvantages of taking part?

As with any form of help that focuses on psychological issues, you may sometimes feel emotionally distressed. The clinicians have experience in delivering one-to-one therapy and will help you to develop methods for managing distress.

A possible disadvantage is the inconvenience of the questionnaires and interviews. These have been kept to a minimum and will be done in a way that is as convenient for you as possible. It is also possible, though unlikely, that you might experience some emotional distress as a result of completing some of the questionnaires. Support will be available to you in this event.

 

What are the potential benefits of taking part?

If you decide to take part than you will be offered help for negative effects of self-criticism. Whilst we expect this form of help to be of benefit to you, we cannot guarantee this. If of interest, we can send you a copy of the final report on the research study.

 

What will happen to the results of the study?

The results of the study will be written up as part of the researchers’ theses, and submitted to a peer reviewed journal and a conference.

 

What will happen if I don’t want to carry on with the study?

You are able to withdraw from treatment or the study at any stage. You may decide that you would like to continue with the intervention, but not complete the questionnaires and interviews. If you withdraw from treatment, with your permission, we would also like you to complete post-intervention questionnaires despite you not completing the individual sessions. However, you will retain the right not to do this if you so choose.

If you withdraw from the study, you may also request that your interview data is removed from this study; this will be possible until one month after the interview.

 

Ethical Approval

This study has been approved by King’s College London Psychiatry, Nursing and Midwifery Research Ethics Subcommittee (PNM RESC) – Reference number [PNM/14/15-33]

 

For further information

If you have any questions or would like any further information about the study, please do not hesitate to contact Alexandra Rose ([email protected]), Ruth McIntyre ([email protected]), Dr Katharine Rimes ([email protected]) or Patrick Smith ([email protected]). If this study has harmed you in any way, you should contact any of the above-named people. If you remain unhappy, you have the right to complain to King’s College London about any aspects of the way you have been approached or treated during the course of this study.

It is up to you to decide whether to take part or not.  If you decide to take part you are still free to withdraw from the study at any time and without giving a reason.

Thank you for taking time to read this information pack.

Summary

  • Participation is voluntary. You have the right to choose not to participate, or to stop participating in the trial at any point and without consequence.
  • All the information you provide throughout the trial will be completely confidential. However, if a member of the team is given reason to believe that your health may be at risk or you may harm yourself or others, we may contact your GP or other relevant parties.
  • This information sheet is for you to keep. If you decide to participate, you will also be provided with a copy of the signed consent form.
  • For any further information, please contact Alexandra Rose ([email protected]), Ruth McIntyre ([email protected]) or Dr Katharine Rimes ([email protected]).

KCL logo without UoL straplineAppendix 11. Participant consent form

CONSENT FORM FOR PARTICIPANTS IN RESEARCH STUDIES

Please complete this form after you have read the Information Sheet and/or listened to an explanation about the research.

Title of Study: Self-criticism: Development of a new intervention

Please tick or initial

King’s College Research Ethics Committee Ref: PNM/14/15-33

Thank you for considering taking part in this research. The person organising the research must explain the project to you before you agree to take part. If you have any questions arising from the Information Sheet or explanation already given to you, please ask the researcher before you decide whether to join in. You will be given a copy of this Consent Form to keep and refer to at any time.

I confirm that I understand that by ticking/initialling each box I am consenting to take part in the study. I understand that it will be assumed that unticked/initialled boxes mean that I DO NOT consent to take part in the study.

*I confirm that I have read and understood the information sheet dated for the above study. I have had the opportunity to consider the information and asked questions which have been answered satisfactorily.

*I understand that my participation is voluntary and that I am free to withdraw at any time without giving any reason. Furthermore, I understand that I will be able to withdraw my questionnaire data up to December 2015 and my interview data up to one month after the interview.

*I consent to the processing of my personal information for the purposes explained to   me. I understand that such information will be handled in accordance with the terms of the UK Data Protection Act 1998.

*I understand that my information may be subject to review by responsible individuals from the College for monitoring and audit purposes.

I understand that confidentiality and anonymity will be maintained and it will not be possible to identify me in any publications

I agree that the research team may use my data for future research and understand that any such use of identifiable data would be reviewed and approved by a research ethics committee. (In such cases, as with this project, data would/would not be identifiable in any report).

I understand that the information I have submitted will be published as a report and I could ask to receive a copy if I wish.

I consent to my interview being audio/video recorded.

__________________               __________________              _________________

Name of Participant                 Date        Signature

Appendix 12. Session protocols

  Session content
Session 1
  • Agenda setting
  • Review of self-criticism
    • The possible effects on thoughts, feelings, physiology and behaviours;
    • The difference between unhelpful self-critical thinking vs. helpful self-corrective thinking;
    • Self-criticism as a habit, i.e. a response to specific contexts and emotional states.
  • Developing shared formulation about self-criticism (see Appendix 9)
  • Psychoeducation about self-compassion approach
    • Distinction between old and new brain;
    • Three emotion regulation systems in brain;
    • Self-criticism and the three emotion regulation systems.
  • Goal of intervention and treatment expectations
    • Aim: reduce/learn to cope with self-criticism;
    • General overview of future sessions;
    • Motivational Interviewing (MI) confidence and importance ratings.
  • Homework setting:
    • Self-monitoring of self-critical thinking;
    • Completing the ‘self-criticism summary’;
    • Reading booklet 1.
Session 2

 

  • Agenda setting, check in and homework review
  • Introduction to self-compassion
    • The teacher metaphor;
    • Definitions of self-compassion;
    • Compassionate attributes – care for wellbeing; sensitivity to distress; sympathy; empathy; acceptance and non-judgement of emotions, and distress tolerance;
    • Compassionate skills – compassionate attention, reasoning, sensations, imagery, behaviour and emotions;
    • Common fears of self-compassion.
  • Using a self-compassionate thought record to develop a compassionate reframe to self-critical thoughts
  • Homework setting
    • Completing further self-compassionate thought records;
    • Reading booklet 2.
Session 3

 

  • Agenda setting, check in and homework review
  • Decentering from the content of self-critical thoughts
  • Changing the context of self-criticism
    • Exploration of the contextual triggers of self-criticism;
    • Planning a behavioural experiment to change the context to reduce the likelihood of self-critical thinking.
  • Relaxation
    • Using Progressive Muscle Relaxation (PMR) to ‘dampen down’ the threat system.
  • Homework setting
    • Continuing with strategies from previous sessions (if appropriate);
    • Changing the context – behavioural experiment;
    • Using decentering in response to self-criticism;
    • Practicing PMR;
    • Reading booklet 3.

 

Session 4

 

  • Agenda setting, check in and homework review
  • Developing a ‘compassionate other image’
    • Rationale for compassionate imagery – links to how the brain processes thoughts and images;
    • Compassionate other image – therapist read through and audio recorded script for participant. Script included physical attributes of image and specific compassionate attributes of the image;
    • Discussion about how to use compassionate other image in response to self-criticism, for example, developing the image further by listening to the script, or using the image to help develop compassionate reframes to difficult situations (i.e. “what would my compassionate image say to me?”)

 

  • Homework setting
    • Continuing with strategies from previous sessions (if appropriate);
    • Using the compassionate other image in response to self-criticism;
    • Reading booklet 4.

 

Session 5

 

  • Agenda setting, check in and homework review
  • Developing the ‘compassionate self’
    • Rationale for the compassionate self – different ‘mindsets’ (patterns of thoughts, feelings and behaviours that we switch in and out of);
    • Use of method acting;
    • Accessing the compassionate self (1) – therapist read through script for participant. Script included accessing own compassionate qualities. Participant then reflected on questions about different aspects of the compassionate self, including their attitude towards themselves, thoughts, feelings, approach to their distress or difficult emotions, behaviours and bodily sensations;
    • Accessing the compassionate self (2) – therapist read through and audio recorded script for participant. Script incorporated participant responses from earlier exercise about their compassionate self.
    • Discussion about how to use the compassionate self in response to self-criticism, for example, by listening to the script, or by ‘guiding their day with self-compassion’.
  • Homework setting
    • Continuing with strategies from previous sessions (if appropriate);
    • Further developing their compassionate self by listening to the audio-recording and/or by guiding their day with self-compassion;
    • Reading booklet 5.

 

Session 6

 

  • Agenda setting, check in and homework review
  • Review of all previous strategies and developing a plan of how to use the strategies between now and the follow-up appointment. Also identifying what could get in the way of being self-compassionate and possible times or situations where they might be less likely to be self-compassionate.
  • Completing the Loving Kindness Meditation – therapist read through and audio recorded script for participant.
  • Ending the intervention
    • Discussions about alternative sources of support (if appropriate);
    • Arranging telephone follow-up appointment;
    • Discussions about collection of feedback about the intervention.

 

Follow-up appointment
  • Agenda setting;
  • General check in and specific discussion about current frequency, intensity and impact of self-criticism;
  • Review of plan about intervention strategies, including frequency ratings of each technique (see below) and plan of how to use strategies going forward;
  • Option to practice any of the strategies;
  • Ending the intervention, including discussions about alternative sources of support (if appropriate).

Appendix 13. Blank participant formulation worksheet

Early Influences Key fears

 

 

External fears

 

 

 

 

 

 

 

 

 

Internal fears

 

 

 

 

 

 

 

Coping strategies Intended consequence Unintended consequences

Appendix 14. Participant booklets

A. Session 1 Booklet

What is self-critical thinking?

Someone who is self-critical will tend to judge themselves in a very harsh way.  They might become disappointed with themselves when they make mistakes, or spend lots of time going over things they don’t like about themselves in their head.  Although we all have self-critical thoughts from time to time, someone who is very self-critical has such thoughts more often and their view of themselves may be particularly negative.

Can self-criticism ever be helpful?

Some people think that self-critical thinking is useful, for example, if we make a mistake a self-critical thought might help us to identify what we could do differently in the future.  However, it would be more accurate to call this ‘self-corrective’ thinking, rather than self-critical thinking.  Self-corrective thinking tends to be very focused on a specific event or issue rather than being about our characteristics or general worth as a person.  Self-corrective thinking tends to focus on a specific mistake or issue that needs to be addressed, while maintaining an overall view of oneself as an acceptable person with strengths and weaknesses.

Are there more unhelpful forms of self-criticism than others?

For highly self-critical individuals, self-critical thinking is often triggered by a specific event but quickly becomes generalised to overall characteristics.  For example, we may quickly conclude from a single mistake that “I am a failure” or “I am not good enough” and feel low or ashamed. Sometimes self-critical thinking is associated with self-hatred and self-contempt e.g. “I am a disgusting person”.  Self-critical thinking may also focus on one’s ability to cope with stress e.g. “I should be able to cope with this” which may be related to frustration. It might lead us to behave in impulsive or unhelpful ways in order to deal with the distressing feelings.  These forms of self-criticism can have particularly negative consequences for us.

What are some common triggers of self-criticism?

Self-critical thinking can affect many different areas of our lives, or may be focused on one or two particular areas.  Here are some common areas in which self-criticism could develop:

  • Work / Study
  • Housework / Cleaning / Tidiness
  • Close relationships (e.g. partner, family, friends)
  • Eating / weight / shape
  • Appearance / Grooming / personal hygiene
  • Sport / Health & Fitness

 

What does self-criticism look like?

Self-criticism doesn’t just affect the way we think.  Self-critical thoughts can also have a negative impact on the way we feel and the way we behave.  See below for common examples of each

Thoughts

  • “I’m stupid”
  • “Mistakes are not acceptable”
  • “I should have tried harder”
  • “I’m useless”
  • “If I don’t achieve 100%, then I have failed”
  • “Everyone will think badly of me”
  • “No-one will ever want to be my partner”
  • “I’ve messed things up again”
  • “I’m not good enough”

Feelings that may arise with self-criticism

  • Bad about oneself
  • Ashamed
  • Low in mood
  • Anxious about not getting things right
  • Tired
  • Worried about details
  • Guilty
  • Angry at mistakes
  • Upset at self
  • Critical of other people too
  • Difficulty feeling calm and content

Behaviours that may occur in relation to self-criticism

  • Put in extra effort or time trying to reach high standards
  • Try to do too many things at once
  • Give up trying
  • Avoid situations where one might be judged
  • Find it difficult to let others help
  • Struggle to make decisions
  • Compare self to others
  • Do things at the last minute (procrastinate)
  • Always keep busy
  • Seek reassurance from others
  • Repeatedly check for mistakes
  • Over-analyse things that have happened
  • Reduce social activities
  • Criticise others, perhaps about characteristics we don’t accept in ourselves
  • Hide feelings from others
  • Overuse certain coping strategies to block out difficult feelings (e.g. food, alcohol, drugs, internet use, exercise, shopping, helping others)

Functions of self-criticism

Self-criticism often develops early in life.  As a result people may believe that they deserve their self-criticism or that it’s an intrinsic part of them.  They may also feel that self-criticism serves an important function for them.  Here are some possible functions:

  • As a warning of threat
  • To push us on to self-correct, improve or achieve
  • As a response to a memory
  • As a habit
  • To avoid aggression from others
  • To criticise ourselves before others do
  • To avoid rejection
  • To reinforce a sense of identity as a humble and unselfish person
  • To get rid of the bad or unwanted feelings inside
  • To bring down positive feelings (e.g. pride) that make us feel uncomfortable
  • As a response to errors or losses driven by panic or frustration
  • To stop us from doing things that could result in harm
  • To protect someone else

All of these functions of self-criticism can be understood as an understandable and protective response of the self to something that is perceived as a threat, from either an internal or external source.

Self-criticism as a habit

As self-criticism is often acquired early in life it can easily become a habit.  If others have been critical of us in the past we may take their views as accurate without questioning them.  We just go along with their criticisms of us, as one often does as a child, and never stop to think if they are accurate or reasonable.  Over time, we internalise the criticism of the other person, so that in their absence, we learn to criticise ourselves.

A habit is formed when people repeatedly respond in a particular way to specific contexts with the aim of achieving a specific goal.  Contexts can include physical settings (e.g. classroom), time of day, the people, behaviours performed prior to (e.g. making a mistake) and internal states (e.g. feeling anxious).  For example, a person may respond with self-criticism when they feel anxious about making a mistake while doing their homework.

For a habit to be learnt the context and the response need to occur close together in time.  Over time, a habit is laid down in our memory system so that we always respond in the same way to the same context.  When there are few alternative options available to us the habit is more likely to become ingrained. In this way, the habit (e.g. self-criticism) can occur without any direct intention or without requiring any particular effort.  The habit may be furthered strengthened when someone sees it to serve a positive function.

Where has self-criticism come from?

Old and new brain

Paul Gilbert, a leading figure in the field of compassion-focused therapy, makes a distinction between our ‘old brain-mind’ and our ‘new brain-mind’. Our brains are the source of our many different feelings, desires, fantasies and motivations.  The basic emotions of anger, anxiety and pleasure have been part of the human experience for a very long time.  They are even ones that we share with other species on our planet.  Our emotions serve a dual purpose, to enrich our lives through the experience of pleasure and joy and to protect us when we experience threat. In modern times, these emotions can bring challenges for us, when they interfere in our daily lives.  For example, people may experience anxiety when there is no apparent threat.  Our ways of relating socially have also been part of the human experience for a very long time.  Looking to chimpanzees, a close relative of ours, we can see how they too engage in social activities and form relationships.  As with our emotions, this social way of relating has both positive and negative elements.  For example, we form close bonds and care for children and each other but we also fight and challenge each other for social position and resources.  Both our basic emotions and social-relating styles are part of our ‘old-brain/mind’ characteristics.  They are ancient motives that guide us in our lives.  We do not choose this way of being but rather it has been decided for us by evolution.

As humans, we are also very different to other species on our planet and have characteristics that represent a ‘new-brain/mind’.  These characteristics are due to changes in our physical brain, which has evolved to become bigger overall and in certain important areas.  For example, the size of the front part of our brain has increased, which has enabled us to have an imagination and to empathise with how others are thinking and feeling.  We also have more capacity to think, learn, use symbols and language and sustain activity, requiring multiple competencies for hours at a time.  The modern brain also has the ability to be creative.  It is because of our new brains that we have witnessed advances in agriculture, science, technology, medicine, culture and psychology.

The problem is when ‘old-brain/mind’ emotions, desires and motives clash with ‘new-brain/mind’ characteristics.  For example, our desire for pleasure may lead us to imagine how our lives might be, free from tiredness, self-doubt, irritability and so on.  When we compare our fantasies to the reality of our lives we may be sorely disappointed.  If we hear a noise during the night and imagine there is a burglar in our house, we may also feel fear and anxiety, whether there is a burglar there or not.  Our ‘new-brain/mind’ also means that we can ruminate and mull over what has happened to us, which may then drive us into a spiral of depression and anxiety.

 

 

 

 

 

 

 

From Gilbert*

The three emotion-regulation systems in the brain

Gilbert outlines three of the major types of emotion regulation systems. These are designed to interact and counterbalance each other. The three systems are outlined below, and the diagram shows how they interact with each other.

  • Threat-protection system: to keep us protected and safe
  • Drive-motivation system: to help us feel driven, excited, activated
  • Contentment-soothing-safeness system: to help us feel content, at peace, connected with others

From Gilbert*

1) Threat-protection system

This system is like an alarm system to detect and pick up on threats quickly.  When threat has been detected, this system is triggered.  This then leads to feelings such as anxiety, anger and disgust, which alert us to the threat.  In turn this then urges us to do something to protect ourselves or others, and leads to behaviours to address the threat e.g. avoiding danger.

This system is designed to protect us, and in many contexts the emotion and associated behaviour may be helpful.  For example, if we detect danger when walking alone late at night, feeling anxious and compelled to run to a safer place might be an appropriate way of keeping safe.  Or if we have an impending exam, some degree of anxiety can help motivate us to revise.  The brain region called the amygdala is involved, which is capable of very quick, pre-conscious detection of threat. The stress hormone cortisol is released, which helps us to respond to threat.

However, sometimes this system can cause problems, if it is too easily triggered or difficult to turn off. Sometimes cortisol production can be over- or under-active. We may become anxious, or angry, or feel that we should avoid situations, even though those emotions and behaviours are not helpful in that particular context. For example, if we feel too anxious, we might find it difficult to sleep or concentrate before an exam.

2) Drive-motivation system

This system helps us to feel sufficiently activated to achieve things and get things done. It leads to our desires by driving us to behave in way to satisfy these. We are motivated by things such as food, sex, friendships, comfort, status and recognition. When these positive things happen, this system gives us a sense of pleasure. Dopamine is one brain chemical involved in this system.

However, if we are over-busy, or push ourselves too hard, this system can get exhausted and we can start to lose feelings of motivation and interest. This can happen if we have been over-using this system for a prolonged period.  Or if the demands of the situation seem overwhelming, or we face the loss of a significant relationship or life goal, we can lose motivation and energy.

3) Contentment-soothing-safeness system

This system regulates the experience of contentment, things being sufficient for us. These peaceful and calm pleasant sensations are very different to the more excited feelings associated with striving and succeeding in the drive-motivation system. This system can help to restore our balance.  This system is evolutionarily important because it underlies our attachments to other people.  These connections are often important for our survival, especially if we are very young or old or ill or vulnerable in some way.  At first our mother soothes us, but over time we can learn ways of soothing ourselves and others.  Humans value and look for kindness in our partners because kindness from others this is a key way of feeling safe and content.  Kindness also underlies trust, which is another fundamental aspect of feeling safe in our connections with other people.  This system is related to brain chemicals such as endorphins and a hormone called oxytocin.

Self-criticism and the three emotion-regulation systems

When self-critical thinking has become a problem, typically the threat-protection system and the drive-motivation system are highly activated, but the contentment-soothing-safeness system is under-used.  So the overall system becomes unbalanced.  According to Gilbert*, someone who is very self-critical may find it difficult to access feelings of (self) warmth, compassion and reassurance.

For example, although most people get stressed by exams, for someone who is very self-critical and believes that anything less than top exam marks would mean failure or being not good enough as a person, this will be especially threatening.  Someone who is very self-critical might also tend to worry a lot about a future exam, and/or ruminate about past mistakes.

Despite what some may believe, self-criticism does not help us to feel motivated or enthusiastic – instead it just adds to the sense of threat.  Similarly, although worrying or ruminating might sometimes give a sense of control with regards to pre-empting future problems or understanding past issues, these processes also keep the threat-protection system active.  So these responses have a high cost.

We may have learnt the sense of purpose or achievement of striving towards our goals.  This is not necessarily problematic unless we rely so much on this strategy that we find it difficult to switch out of Achievement / Striving mode.  For example, someone may criticise themselves and then feel guilty if they spend any time where there is not some kind of ‘achievement’ at the end.  Relaxing, having fun, and spending ‘unproductive’ time with friends or family, can get neglected.

Sometimes if we are not feeling enough sense of achievement in one area (e.g. work), we have learnt that focusing on another area of achievement can give us the positive feeling.  For example, we might find that striving towards being very physically fit, or keeping our possessions very tidy and in order, or keeping to a strict form of diet, or having an immaculate clothes / make-up, or looking after other people, or maintaining standards in another area, helps us to feel better about ourselves or more in control.  These are not necessarily problematic but if someone tends to experience lots of self-critical thoughts, we have to be careful that we do not pursue them inflexibly or spend too much time on them.  Otherwise, we can lose sight of what is really more important to us, in terms of our values and health, in the long-term.

Striving towards achievement in these ways can sometimes make us feel temporarily better but does not address an underlying sense of not being ‘good enough’, so this remains vulnerable to getting triggered off again.  Although achievement is an important part of feeling good about ourselves, no-one can be successful all the time.  When things go wrong or we make mistakes or fail, often the most effective way of coping is to be able to be kind and supportive to ourselves, and / or to seek support and connection with others.  When we are feeling calmer, we are in a better position to take stock, look at the bigger picture and make a wise decision about where to focus our efforts in the future.

Some of us are not confident in our ability to soothe ourselves or seek care and connection and support from others.  This is usually because past circumstances have not provided that opportunity.  However, it is never too late to learn ways to be more self-compassionate and kind towards ourselves and to develop and maintain warm and supportive relationships with other people.

Someone who is very self-critical may experience a sense of resistance when they hear this. For example, it may sound self-indulgent or unnecessary.  This is not self-indulgence, it is about treating the mind wisely with what it need to function at its best.  Developing the flexibility to switch between these systems will result in better health and functioning than spending too much time with the Threat system activated.

 

Effects of self-criticism

Our thoughts and images can have a very powerful effect on our brains and bodily systems. Imagine that you are very hungry and you sit down to eat your favourite dinner.  What is the effect of this on your body?  When you see the food in front of you, an area of your brain is stimulated, which sends messages to your body so your mouth will start to produce saliva and your stomach will start to produce digestive juices.  This has the effect of making your mouth water and your stomach rumble. Imagine now that you are really hungry but you have no food left in your house, so you close your eyes and imagine your favourite dinner.  What is the effect of this on your body? The same as what happened when you actually had your favourite dinner in front of you.  Your mouth starts to water and your stomach starts to rumble, even though this time you are only imagining your favourite food.  The image in your mind is so powerful that it can stimulate the same physiological systems in your body.

Now think about what happens in your body when you are under threat.  For example, if you are being bullied emotionally or physically by another person, or are being criticised or having your mistakes pointed out to you in a harsh manner, you are likely to feel threatened.  Being threatened stimulates the stress system and your body produces the stress hormone cortisol.  This can cause physical symptoms such as muscle tension, nausea and sweaty palms.  It also makes people feel anxious and upset.  This happens because the threat emotion systems in the brain have been triggered.  If the threat persists, for example, if you are constantly being bullied every day, you may become very distressed, unhappy and depressed.  This makes a lot of sense.  The very same effect can also occur in response to threatening thoughts and images in our minds.  So, if you are constantly putting yourself down or being self-critical, your stress system will be activated triggering the emotional systems in your brain that make you feel anxious, angry and down. It will also have the effect of curbing positive feelings.  Thus, for those people who tend to be self-critical, their threat systems are frequently being stimulated and they understandably feel more anxious, angry or depressed.

From Gilbert *

Below are some further examples of possible effects of self-criticism:

 

  • Feeling anxious, angry and down
  • Physical exhaustion from constantly feeling under threat
  • Feeling disgusted and ashamed of oneself
  • Rarely feeling safe, happy or relaxed
  • Setting unattainable standards for oneself
  • Comparing oneself to others in a negative manner
  • Never feeling satisfied with oneself
  • Ruminating on perceived flaws and mistakes
  • Difficulties forming and maintaining relationships
  • Psychological problems such as depression, eating disorders and self-harm

 

 

 

Starting to become aware of self-critical thinking (self-criticism monitoring)

When someone experiences lots of self-critical thoughts, this way of thinking will start to become a habit.  This means that the self-critical thoughts will become so automatic that we might not even realise that we are having them.  Greater awareness of a habit is the first step in changing it. The Self-Critical Monitoring Form on the next page will help you do this.  We will use this form to write down the following:

Context and triggers:  Are there particular contexts where self-critical thinking is more likely, for example certain times of day or situations?  Is it more likely after certain triggers such as having made a mistake or having said something you regretted or feeling evaluated or criticised by others?

Feelings:  How were you feeling before the self-criticism started?

Duration:  How long did the self-critical thinking last?

Content: What were you thinking about? Try and write down exactly what the self-critical thoughts were.

Consequences:  What were the consequences of the self-criticism? Self-critical thoughts can have a negative impact on our mood and on our behaviour.   How did you feel after the self-critical thoughts occurred? Did you do anything in response to these thoughts?

What stopped the self-criticism?  Did you try anything to stop the self-criticism?  Was this useful? Or did it stop due to external factors?

Self-critical monitoring form

Please could you fill in details about TWO examples of you being self-critical.  There are no right or wrong answers – it’s just a way of gathering helpful information about your thinking.

What happened just before the self-criticism started? How did you feel before? Duration What were you thinking about? What were the consequences of the self-criticism – on mood and actions? What stopped the self-criticism? What did you do to try to stop it? Was it useful?

Understanding your self-criticism

Once you have become more aware of the self-critical thinking, it can be useful to summarise what you noticed by filling in the Self-Criticism Summary form on the next page.  A couple of examples are also included on the following pages.

Self-Criticism Summary

 

Themes

 

 

Common examples

 

 

When does it happen?

 

 

What stops / interrupts?

 

 

Aims of the self-criticism (e.g. how is it intended to help keep you safe?)

 

Aims and possible advantages:

 

 

Disadvantages:

 

 

Can the self-criticism lead to things being avoided?

 

 

How did self-criticism develop into a habit?

 

 

Any times or situations when you are less self-critical? What helps?

 

 

 

Matt’s example

Themes

  • Concerns about what friends think of me
  • Feeling inadequate at Uni work or in job

 

Common examples

  • “I shouldn’t have said that to my friends, they’re going to think I’m stupid”
  • “That was a useless piece of coursework”
  • “I’m such an idiot”

 

When does it happen?

  • When I meet up with friends (with some more than others)
  • When I meet my university tutor
  • When I try to do my coursework or get my grades back
  • When I serve customers at work

 

What stops / interrupts?

  • When I’m distracted by something else

 

Aims of the self-criticism (e.g. how is it intended to help keep you safe?)

 

Aims and possible advantages:

  • I think about what I say to my friends more
  • I look out for mistakes on my coursework

 

Disadvantages:

  • It makes me more worried in social situations
  • I worry about my coursework
  • I get angry with myself when I make mistakes

 

Can the self-criticism lead to things being avoided?

  • Sometimes I avoid starting my coursework
  • Sometimes I cancel on my friends or say less in social situations because I’m worried what others will think

 

How did self-criticism develop into a habit?

  • When I was younger, my parents wouldn’t often criticise me directly but I could tell they wanted me to be more academic like my older brother and sister
  • Teachers were often quite critical, maybe because they were expecting me to be as clever as my brother and sister and thought I wasn’t trying hard enough

 

Any times or situations when you are less self-critical? What helps?

  • When I play sport

Sophie’s example

Self-Criticism Summary

 

Themes

  • Concerns about dating
  • Feeling unhappy about appearance

 

Common examples

  • “Nobody would ever want to go out with me”
  • “If I went on a date I’d probably make a mess of it and never hear from the guy again”
  • “I’m not as pretty as the other girls”
  • “My bum is too big.
  • “If a guy saw me naked he would never want me as a partner”

 

When does it happen?

  • When my friends are talking about the guys they are dating
  • When I’m at a party and I see someone I’m attracted to
  • When I see a really pretty girl at Uni or at work
  • When I’m shopping for clothes with my mum
  • Seeing myself in the mirror

 

What stops / interrupts?

  • When I’m distracted by work or something else

 

Aims of the self-criticism (e.g. how is it intended to help keep you safe?)

Aims and possible advantages:

  • It helps stop me getting over-confident and making a fool of myself
  • It helps me avoid getting rejected by guys and feeling bad
  • It helps prevent me looking as bad as I could do (e.g. check hair / appearance in the mirror)

 

Disadvantages:

  • I don’t feel very confident
  • If a guy might be interested, I get anxious and can’t be myself when I’m talking to him. If I do manage to talk to a guy, I spend ages afterwards worrying what he thought of me
  • I feel lonely when my friends are with their partners or on dates
  • I feel jealous when I see how pretty my friends are
  • I don’t feel able to wear the same type of clothes as my friends because I want to hide my body
  •  

Can the self-criticism lead to things being avoided?

  • Sometimes I avoid talking to or even being near people I’m attracted to
  • I won’t try dating online or take any active steps to get into dating
  • I avoid going shopping for clothes with my friends
  • I avoid exercising in public

 

How did self-criticism develop into a habit?

  • When I was growing up my mum used to make it clear that boys only like pretty girls with good figures. She thought it would help me keep control of me weight and take care of my appearance. She does not seem very happy with her own appearance but works hard to make the most of herself.
  • When the boys at school would laugh when I walked by I was sure they were thinking I was really ugly and would never be attracted to me
  • Being self-critical of my appearance helped me be careful about how I look – that made me feel more in control and a bit safer from other people’s judgments
  • It just feels safer than making myself vulnerable to rejection

 

Any times or situations when you are less self-critical? What helps?

  • When I’m feeling relaxed and doing something fun with my friends
  • Some of my friends know how I feel underneath, and are really supportive and can make me feel better temporarily
  • When I’m doing my volunteer work I forget about myself (although I can also get self-critical that I should be grateful for what I’ve got!)

Acknowledgement:

The content of this booklet drew on the following resources:

Books

*Gilbert, P. (2009). The Compassionate Mind. Constable: London.

*Gilbert, P. (2010). Compassion Focused Therapy. Routledge: London, New York.

*Gilbert, P. (2010). An Introduction to the Theory and Practice of Compassion Focused Therapy and

Compassionate Mind Training for Shame Based Difficulties. Downloaded from

www.compassionatemind.co.uk/resources/training_materials.htm

*Gilbert, P. & Choden, P. (2014). Mindful Compassion: how the science of compassion can help you understand your emotions, live in the present, and connect deeply with others. New Harbinger Publications, Inc: Canada.

Welford, M. (2012). The Compassionate Mind Approach To Building Your Self-Confidence.

Robinson: London.

Articles

*Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment, 15, 199-208.

*Gilbert, P. (2010). An introduction to compassion focused therapy in cognitive behavior therapy. International Journal of Cognitive Therapy, 3, 97-112.

 

 

 

 

Appendix 13. Participant booklets

  1. Session 2 Booklet

Self-compassion as an alternative to self-criticism

In order to change a habit it is helpful to have an alternative option to turn to and cultivate. The self-compassion approach helps us to recognise our self-critical tendencies, respond to them with understanding and kindness, while moving us towards more helpful self-correction.  Compassionate self-correction focuses on the desire to improve ourselves or our situation.  It is focused on the future and is given in the context of encouragement, support and kindness. It is in contrast to self-criticism focuses on the desire to attack or punish ourselves and is often focused on past mistakes.  Self-criticism is usually in the context of anger, annoyance and frustration (Gilbert, 2010, P. 106).

Self-compassion helps people to recognise self-criticism as a component of the threat system.  It also helps people to become aware of the emotions associated with self-criticism and to understand the function, possible origins and the reasons why one might agree with their self-criticism.  Self-compassion can help people to move out of the threat system by evaluating the legitimacy of the self-critical self-attacks.

The Teacher Metaphor

One way to think about the differences between the two approaches is to consider the ‘teacher metaphor’ in relation to a child who is struggling in class.  Imagine one teacher who is encouraging and supportive of the child and rewards the child for what s/he has done well. How might this child feel?  Now imagine another teacher who is critical and harsh with the child and punishes the child for the mistakes s/he has made.  How might this child feel? Which style of teaching is likely to develop the child’s confidence, enthusiasm and happiness?  Which way would you prefer to treat yourself?

 

What is self-compassion?

 

Self-compassion involves directing compassion, which may be defined “as a sensitivity to the suffering of self and others with a deep commitment to try to relieve it” (Dalai Lama), towards ourselves.  In this way, we learn to move out of the threat-focused system and into the soothing/compassion-focused system.  This can help us to balance our emotions and enable us to experience a much greater sense of wellbeing.

Gilbert* has distinguished between compassionate attributes and compassionate skills.  By developing these attributes and skills, we can helpfully manage the negative impact self-criticism has on our thoughts, feelings and behaviours.

Compassionate Attributes (adapted from Welford* P. 73-76):

Warmth, gentleness and kindness

All of the attributes listed below are “experienced in the context of emotional warmth” (Welford*, P 73).

  1. Care for well-being

This means having the intention, motivation and commitment to care about the welfare of yourself and of other people.

 

 

  1. Sensitivity to distress

This involves being aware of when you or others are experiencing distressing or difficult emotions, and being open to such experiences.

 

 

  1. Sympathy

This means being emotionally touched by what is happening in our lives or other people’s lives and connecting with whatever pain is present. 

  1. Empathy

This means having an understanding of our minds and the minds of others, and being able to consider things from various perspectives. It allows us to think about what one might need. 

  1. Acceptance and non-judgement of emotions

This means recognising the complexity of human experience and doing our best not to judge or condemn what happens in our lives as well as our thoughts, feelings and behaviours.

  1. Distress tolerance

This means being able to tolerate or feel difficult emotions, memories or situations even when we would rather avoid them.

Compassionate Skills:

As well as the compassionate attributes, Gilbert* has also identified a number of skills – these are things that we can learn to do:

  1. Compassionate attention

This involves noticing when things have gone well, or if things don’t go as we would like, learning from this, rather than dwelling on the negative.

 

 

  1. Compassionate reasoning

This involves bringing balance to our thinking by considering all the evidence and reducing any unhelpful thinking patterns that we might use.

 

  1. Compassionate sensations

This involves noticing feelings in our bodies when we focus on being compassionate.

  1. Compassionate imagery

This involves developing images in our mind that are “supportive, understanding, kind and encouraging” (Welford*, P. 76) and using these images to help us.

  1. Compassionate behaviour

This involves behaving in a caring and supportive manner that, at times, may require courage.

 

 

  1. Compassionate emotions

This involves developing an emotional tone that emphasises support, warmth and kindness.

 

Common fears & blocks to self-compassion

Below are some common fears and blocks to compassion that Gilbert* has identified:

  • Feeling like you don’t deserve it.
  • Thinking that self-compassion is self-indulgent or selfish.
  • Seeing self-compassion as a weakness.
  • Feeling sad and tearful when you try to be self-compassionate.
  • Having unpleasant associations with kindness.
  • Feeling angry and thinking that compassion won’t help you.
  • Thinking that compassion means you have to be a “nice person” all the time.
  • Thinking that compassion allows you to go easy on yourself.

When we are trying to change an old habit and introduce a new one, things can sometimes get in the way of us making the change.  It is normal to face some barriers along the way.  Sometimes we can be actively resistant to change and other times the new way of doing things just seems a bit strange.  This may be true even if we believe that the change we are hoping to make is an important one.   It is not unusual to feel a sense of resistance or discomfort about the idea of treating oneself with self-compassion.  For example, we may have thoughts that we don’t deserve it, or that we shouldn’t have to do that or that it’s ‘wet’ or weak. It may sound impossible.  We may have concerns that it will make us too complacent, but self-compassion includes acknowledging mistakes in a constructive way.  We can worry that being self-compassionate will make us selfish.  However, it is often more difficult to care for others well and be accepting of them if we are treating ourselves harshly.  People often report that when they are kinder to themselves, they feel more positively towards other people too.

People who are not self-critical often automatically treat themselves kindly without even thinking about it – it has become a habit in the same way that self-critical thinking has become a habit for others.  We can all learn to be more self-compassionate but it takes practice.  It can be helpful to think about it in terms of your physical health. If you hurt your arm in an accident and suspected you had pulled a muscle, you wouldn’t tell yourself you don’t deserve for it to get better.  Instead, you would take yourself to the doctor and do the recommended physiotherapy exercises to build your arms strength back up again. It might take some time and effort but you know that it will be worth it in the end.  The same is true when we have been hurt internally by our own self-critical thinking. Once, you have developed the skills of self-compassion you can then decide if it is a helpful approach for you or not.

Dealing with Mistakes and Failure

Sometimes people who are highly self-critical might worry about what will happen if they do not criticise themselves strongly if they make mistakes or fail. For example, they may be concerned that they will become arrogant, selfish, lazy or uncontrolled.   However, there are ways of dealing with mistakes and failure in a compassionate way that allows for self-correction and self-improvement without being so hard on ourselves. Differences between compassionate self-correction and fear-based self-criticism are shown in the table below.

Compassionate self-correction Fear-based self-criticism 
  • Driven by hope and belief in success
  • Positive focus on improvement
  • Future-focused
  • Is provided with encouragement, support and kindness
  • Acknowledging what one has done well as well as what can be improved
  • Considers mistakes and failure as potential learning opportunity
  • Is specific: focuses on a particular behaviour or specific characteristics of the self
  • Driven by fear
  • Negative focus: self-judgment or even punishment
  • Often focuses on the past
  • Is provided with frustration, anger or,  dissatisfaction
  • Attends only to weaknesses and fear of these being revealed
  • Views mistakes and failure as a shameful experience
  • Is over-general: emphasizes the self as a whole

(Adapted from Gilbert, 2010, p. 106)

It is compassionate to take ourselves seriously and acknowledge our feelings of fear, anger and shame.  It’s not so much whether we have any of these feelings but rather how we relate to them and what we do about them. For example, if you have a fear of going outside, it might feel nice to stay indoors and watch television, but this will not help you in the long run.  Compassion helps us to develop the courage to face our fears whatever they might be.

Helpful questions to learn more about your potential barriers to self-compassion

As you practice engaging in a more compassionate way of thinking, notice if there are any barriers stopping you.  Here are some questions you might ask yourself as you try to understand these more:

  • Did anything go through your mind that made you want to stop?
  • Did you think you weren’t doing the exercise properly?
  • Did you think it was pointless because it wasn’t going to help you anyway?
  • Was there a voice in your head saying you don’t deserve kindness?

 

  • Did your emotions become too intense?
  • Were you feeling scared or vulnerable?
  • Did you start to feel sad or lonely?
  • Were you feeling angry?
  • Did any feelings of shame come up for you?

 

  • How was your body feeling as you were doing the exercise?
  • Did you have difficulty finding a soothing breath?
  • Did you become dizzy or shaky?
  • Did you feel really tired?

 

Self-compassionate thought record

Compassionate thinking and reasoning is an important skill to develop. Our brains have evolved in such a way that our anxieties and fears often control how we think about certain things.  This is understandable as at even the slightest sign of threat our minds step in to protect us.  This, however, can be unnecessary and may have the unfortunate effect of making us feel anxious, depressed, angry and paranoid.  One helpful thing to bear in mind is that no thought or feeling that you have has not already been experienced by another human being.

The purpose of completing a self-compassionate thought record is, therefore, to help you to identify a more balanced and helpful way of thinking about a situation.  Why we do this is because we know that generating alternatives can help us to flourish, grow and develop wisdom.

Please take a look at the examples of completed thought records on the following pages. You will see that the function of the self-criticism is purely threat-focused, over-general and catastrophic e.g. avoiding losing friends or academic failure. The self-compassionate approach does not ignore the possibility that something does need to change. However, the self-compassionate approach is more specific about exactly what happened, identifying with kindness why it might have happened, and what specifically you might need to do differently in the future. Crucially, the self-compassionate approach also addresses how to deal with how you are feeling.

Here are some questions you might ask yourself as you complete your compassionate thought record:

  • What would I say to someone I cared about who was in this situation?
  • What would a good friend say to me about this?
  • What would a coach say?
  • What would be a compassionate approach to this situation?
  • How can I remind myself that mistakes and weaknesses are part of everyday life and do not imply anything about my worth as a person?
  • How can I learn from this?
  • How would I see this situation if I wasn’t feeling stressed, anxious, frustrated, upset or uptight?
  • How will I feel about this situation in the future – will I even remember it?

 

Triggering Events, Feelings or Images Self-critical thoughts Feelings Compassion-focused Alternatives to Self-Critical Thoughts Understanding and change in feelings
Key questions to help you identify your thoughts.

 

What actually happened? What was the trigger?

What went through your mind?

What are you thinking about others, and their thoughts about you?

What are you thinking about yourself, and your future?

 

What are your main feelings and emotions?

 

 

What would you say to a friend?

What compassionate alternatives might there be?

What is the evidence for new view?

(How) are these examples of compassion, care and support?

Can you think these through with warmth?

 

Write down any change in your feelings.

 

Having lunch with my friends. They were talking about their weekend plans. I was very quiet and didn’t join in the conversation. Self-critical thoughts:

I have nothing interesting to say. I’m really boring. I seem really rude. I’m not a very good friend.

 

Key feared Consequences:

People will think I’m rude. They will get sick of me and won’t want to be friends with me anymore.

Function of the self-criticism:

To try to avoid losing my friends

 

Annoyed (at myself), anxious, worried, irritated

 

Compassionate alternative:

It’s ok to be quiet sometimes in conversations – they are my friends and understand when I’m not feeling chatty.  Sometimes other people are quiet and I don’t think badly of them. I had a busy morning and was still thinking about things that had been going on. It’s understandable then that I was quiet.  The self-criticism is just my threat-system talking

Any compassionate actions needed? (If so, what?)

 I feel better about this but if the thoughts come back I can remind myself that my friends accept me whether I’m chatty or quieter. Now I can focus on addressing what happened this morning rather worrying about what my friends think of me**

Function of the self-compassionate approach:

To address my concerns about what other people think of me in a kind and balanced way, and identify anything I need to do to feel better

I feel less annoyed and irritated. I feel more understanding of why I might have been quiet. My anxiety has reduced.

**It’s ok to have thoughts about how you come across to other people – we all do – but we must try to deal with these thoughts kindly and think about both sides rather than just being focused on the threat. Another time the conclusion in this example might have been that the person does need to join in more, e.g. if this is a repeated pattern of behaviour and they’re not joining in out of fear of what others think. If that was the case the person would need to come up with a self-compassionate understanding of the avoidant behaviour and how to deal with it in a compassionate way.

Triggering Events, Feelings or Images Self-critical thoughts Feelings Compassion-focused Alternatives to Self-Critical Thoughts Understanding and change in feelings
Key questions to help you identify your thoughts.

 

What actually happened? What was the trigger?

What went through your mind?

What are you thinking about others, and their thoughts about you?

What are you thinking about yourself, and your future?

 

What are your main feelings and emotions?

 

 

What would you say to a friend?

What compassionate alternatives might there be?

What is the evidence for new view?

(How) are these examples of compassion, care and support?

Can you think these through with warmth?

 

Write down any change in your feelings.

 

I logged on to look at my mark for my last essay. I got 56%. Self-critical thoughts:

It’s not good enough. I didn’t work hard enough. I’m stupid. I’m useless.

 

 

 

Key feared Consequences:

If I don’t work hard enough I might fail my course.

Function of the self-criticism:

To try to avoid academic failure.

 

Anger, annoyed, upset, disappointed, sad

 

Compassionate alternative:

A friend might remind me that although I rushed the essay I did work hard on it. I tried my best. It was a topic I find quite difficult. My tutor’s comments have some useful pointers for next time. Next time I could spend more time planning the structure. Or I could ask someone to read through it. It’s only one essay and I have done well on other essays.  My grade doesn’t mean I’m stupid.

Any compassionate actions needed? (If so, what?)

 I know what I’m going to do next time – allow more time on essays on this topic and get more help. No need to go over this any more so now I am just going to call a friend and talk about other things.

 

 

Function of the self-compassionate approach:

To help identify specific things that will support me achieving my academic potential, plus anything I need to do to feel better now.

 

I still feel a bit disappointed but I’m not so angry and annoyed at myself.

Triggering Events, Feelings or Images Self-critical thoughts Feelings Compassion-focused Alternatives to Self-Critical Thoughts Understanding and change in feelings
Key questions to help you identify your thoughts.

 

What actually happened? What was the trigger?

What went through your mind?

What are you thinking about others, and their thoughts about you?

What are you thinking about yourself, and your future?

 

What are your main feelings and emotions?

 

 

What would you say to a friend?

What compassionate alternatives might there be?

What is the evidence for new view?

(How) are these examples of compassion, care and support?

Can you think these through with warmth?

 

Write down any change in your feelings.

 

Seeing someone really attractive at Uni, on the street or watching television  Self-critical thoughts:

I’m really ugly.

I have a weird body. Maybe there is no point trying to meet a partner.

 

 

Key feared Consequences:

Nobody will ever be attracted to me so I will end up alone.

Function of the self-criticism:

To try to protect me from the pain of rejection. To try to motivate me to try to improve my appearance. 

Shame, sadness, hopeless, anxiety

 

Compassionate alternative:

Lots of people have concerns about their appearance; magazines and television make it seem like everyone should look a certain way. It’s not surprising I’d compare myself to others and then feel bad about myself. It would be better for me to accept myself as I am. Plus, I’m not completely ugly, I’ve been told that that I have a nice eyes and a pretty smile. Even if I don’t meet someone romantically my friends and family will still love me so I won’t be alone.

Any compassionate actions needed? (If so, what?)

I can increase the chances of meeting someone by being proactive about dating rather than avoiding it. This may take some time (for anyone!) so I need to be very self-compassionate if there are unsuccessful dates before I finally meet a potential partner

 

Function of the self-compassionate approach:

To help me maximise my chances of meeting a partner

Calmer, more accepting and more hopeful

Blank copy – Thought record from Gilbert*

 

Triggering Events, Feelings or Images Self-critical thoughts Feelings Compassion-focused Alternatives to Self-Critical Thoughts Understanding and change in feelings
Key questions to help you identify your thoughts.

 

What actually happened? What was the trigger?

What went through your mind?

What are you thinking about others, and their thoughts about you?

What are you thinking about yourself, and your future?

 

What are your main feelings and emotions?

 

 

What would you say to a friend?

What compassionate alternatives might there be?

What is the evidence for new view?

(How) are these examples of compassion, care and support?

Can you think these through with warmth?

 

Write down any change in your feelings.

 

Self-critical thoughts:

 

 

Key feared consequences:

 

Function of the self-criticism:

  Compassionate alternative:

Any compassionate actions needed? (If so, what?)

 

 

Function of the self-compassionate approach:

Acknowledgement:

The content of this booklet drew on the following resources:

Books

*Gilbert, P. (2009). The Compassionate Mind. Constable: London.

*Gilbert, P. (2010). Compassion Focused Therapy. Routledge: London, New York.

*Gilbert, P. (2010). An Introduction to the Theory and Practice of Compassion Focused Therapy and

Compassionate Mind Training for Shame Based Difficulties. Downloaded from

www.compassionatemind.co.uk/resources/training_materials.htm

*Gilbert, P. & Choden, P. (2014). Mindful Compassion: how the science of compassion can help you understand your emotions, live in the present, and connect deeply with others. New Harbinger Publications, Inc: Canada.

Welford, M. (2012). The Compassionate Mind Approach To Building Your Self-Confidence.

Robinson: London.

Articles

*Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment, 15, 199-208.

*Gilbert, P. (2010). An introduction to compassion focused therapy in cognitive behavior therapy. International Journal of Cognitive Therapy, 3, 97-112.

Appendix 13. Participant booklets

C. Session 3 Booklet

Compassionate alternatives to self-criticism

In order to turn self-compassion into a new habit we have to practice it as much as we can.  Once you have practiced the Self-Compassionate Thought Record a number of times, try focusing on these key columns.

Self-critical thoughts Compassion-focused Alternatives to Self-Critical Thoughts Any compassionate actions needed? (If so, what?)
What went through your mind?

What are you thinking about others, and their thoughts about you?

What are you thinking about yourself, and your future?

 

What would you say to a friend?

What compassionate alternatives might there be?

What is the evidence for new view?

(How) are these examples of compassion, care and support?

Can you think these through with warmth?

 

 
Self-critical thoughts:

 

 

Compassionate alternative:

 

 

 

 

 

 

 

Decentre: Change how you relate to the self-critical thoughts

Self-critical thoughts may pop into your head even if you have made a decision not to elaborate on them or develop them further. We cannot control the thoughts that pop into our head, only what we do next.

Alternatives to getting caught up in the content of overthinking:

  • Notice the streams of thinking, for example as though standing behind a waterfall or watching storm clouds passing overhead – watching the process rather than the content
  • Name the process e.g. “Here is self-criticism / ‘Critical Mind’ / “Judgmental mind“ again”
  • Remind yourself that thoughts are not facts, even those that say they are!
  • Remind yourself that the thoughts that pop into your head are not ‘you’ but are simply passing mental events.
  • Give yourself permission to let the thoughts arise and pass, rather than becoming involved with their content.
  • If the thoughts keep popping into your head, just continue to observe this process e.g. “The thoughts keeping coming into my head”. There is no need to become self-critical about experiencing the self-critical thoughts!
  • Trying to suppress the thoughts may not work and may be counterproductive if you are feeling upset, but become absorbed in pleasant or engaging activities might help to make you feel better until the thoughts die down.
  • Remember that all bouts of self-critical thinking do pass with time.

Change the context

You may be more likely to be self-critical in certain situations. Changing aspects of the context could help reduce excessive self-critical thinking. Different strategies work for different people and you may need to try a few things before finding what is most effective. There are some examples listed below but you may find it helpful to talk to your therapist about your own situations.

Examples of changing the context to reduce self-critical thinking

Situation where self-critical thinking is more likely to occur Examples of changes to the situation
“Before I get up I lie in bed over-thinking things; especially at the weekend” Getting up straight away. Some people find it can help to have a specific activity to get up for e.g.  exercise class , meeting friend for breakfast.
“When I’m in the shower or travelling to or from Uni / work” Listening to cheerful music or interesting radio programme or podcast.
“When I get home in evening, I’m tired and collapse in front of tv but often end up going over things that have happened that day, over-analysing what people might have thought of me or things I should have done differently” Getting on with preparing dinner instead, or watching something that you have recorded / on internet that you particularly enjoy, or doing some yoga or a relaxation exercise (see later in booklet), or another absorbing activity such as phoning friend.
“When I’m alone at home. This happens particularly at the weekend which I try to keep free for studying. I don’t actually end up studying all weekend but then miss out on seeing other people or doing fun things”. Planning social and enjoyable activities at the weekend too, as well as specific times for studying if needed.
“At the gym. I don’t really enjoy the gym anyway but want to be healthy”. Going to a different gym or going with a friend or a different time of day. Switching to a different form of exercise where you can relate to other people in a more positive way (e.g. team sport, exercise class that’s not competitive) or exercising on your own (e.g. walking, running, swimming).
“Talking to my Mum. It’s important to me that I do speak to her once a week but I always feel self-critical afterwards” Phoning at a different time of day when you’ll be busy afterwards or not on your own. Having a planned activity to do straight afterwards – something that will absorb your attention.

Change your Physiology: Dampen down the Threat System

Self-critical people often have difficulty fully relaxing. Dampening down the Threat system can not only make you feel calmer and more relaxed, it can also have a positive impact on your thinking style. You will probably find it easier to access more balanced ways of relating to yourself and the situation.

There are a wide range of relaxation exercises – here are a couple of examples:

Controlled abdominal breathing (adapted from http://psychology.tools/relaxation.html)

  • First, get into a comfortable position that supports your head, back and arms, and put your feet flat on the floor.
  • Close your eyes (if that feels comfortable).
  • Put one of your hands on your abdomen beneath your rib cage.
  • Take a deep breath in slowly, and try to send the air as low and deep into your lungs as is comfortable. When you breathe from your abdomen, you should feel your hand rise (instead of your chest).
  • When you have taken a deep breath, pause before breathing out. As you breathe out, maybe imagine all of the tension draining from your body.
  • Try to do 10 breaths like this. Breathe in slowly and count to 4, before breathing out to the count of 4 (in for 4 seconds, out for 4 seconds).
  • Repeat this type of breathing for as long as feels comfortable.

 

Progressive Muscle Relaxation

Progressive muscle relaxation (PMR) is a technique that was developed by Dr. Edmund Jacobson in the 1920s. Jacobson highlighted that anxiety and stress lead to muscle tension, which then further increases feelings of anxiety. On the other hand, when the body is relaxed there is less muscle tension, leading to less anxiety.

Muscle tension is usually an automatic process and therefore not something we tend to notice. The aim of PMR is to help you identify tension in your body and your muscles, and ultimately become more relaxed.

There are a number of physical changes and sensations that occur in the body when we are stressed or anxious, including:

  • Increased blood flow to the muscles
  • Tight muscles
  • Rapid and shallow breathing
  • Increased heart rate
  • Slow digestive functioning

PMR can counter these physical changes to achieve a “relaxation response” by calming your body. When relaxed, your breathing becomes slower, and your heart rate and blood pressure decrease. When your muscles are relaxed, they do not need as much oxygen as when they are tense. This causes redirection of blood flow from the tense muscles to other areas of the body, which then reduces a lot of the unpleasant physical sensations associated with anxiety.

How to do Progressive Muscle Relaxation?

PMR involves tensing and relaxing various muscle groups in your body in a systematic way.

Progressive Muscle Relaxation Exercise for 16 Muscle Groups

If you would like to try this, you could choose 1-2 times during your day when you can spend 15-30 minutes alone, uninterrupted and in a quiet room.  PMR can be done sitting or lying down – whatever is most comfortable.

Before you begin, try some deep breathing; inhale slowly and deeply through your nose and exhale through your mouth. Then repeat this as many times as feels comfortable.

After you have done some deep breathing tense each of the muscles in the following muscle groups for about 7-10 seconds (or what feels comfortable), release the muscles, and then concentrate on the pleasant sensations of relaxation for the about 20-30 seconds. You can repeat the same muscle group and then go on to the next muscle group once the previous group feels completely relaxed.

 

Muscle Groups to Use

  • Right hand and forearm (to tense: make a tight fist)
  • Right biceps (to tense: push your elbow down and inward against your side)
  • Left hand and forearm (to tense: make a tight fist)
  • Left biceps (to tense: push your elbow down and inward against your side)
  • Forehead and top of head (to tense: lift your eyebrows)
  • Eyes, nose, and top of the cheeks (to tense: squint your eyes very tightly and wrinkle your nose)
  • Mouth, jaw, and the side of the cheeks (to tense: bite your teeth together and pull the corners of your mouth back)
  • Neck and throat (to tense: pull your chin downwards towards your chest and at the same time try to prevent it from actually touching your chest)
  • Upper chest, back and shoulders (to tense: take a deep breath, hold it in, and at the same time pull your shoulder blades together)
  • Abdomen (to tense: make your stomach hard)
  • Right upper leg (to tense: push your foot down into the ground)
  • Right calf (to tense: pull your toes upwards towards your legs)
  • Right foot (to tense: point and curl your toes, turning the foot inward)
  • Left upper leg (to tense: push your foot down into the ground)
  • Left calf (to tense: pull your toes upwards towards your legs)
  • Left foot (to tense: point and curl your toes, turning the foot inward

 

Below are some example PMR audio-recordings:

http://services.unimelb.edu.au/__data/assets/mp3_file/0003/965442/PMR.mp3

http://www.mentalhealth.org.uk/help-information/podcasts/progressive-relaxation-sleep/

 

Compassionate imagery

One technique that can be used to develop self-compassion is imagery.  The purpose of imagery is to stimulate positive feelings and to help you feel soothed. It also has a positive effect on our neuro-physiology by developing our soothing system.

In session 1 we described the effects of self-criticism.  We described our thoughts and images can have a very powerful effect on our brains and bodily systems.

We described that if we are criticised by another person for a mistake we have made, we are likely to feel threatened. Being threatened stimulates the stress system and your body produces the stress hormone cortisol. This can cause physical symptoms such as muscle tension, nausea and sweaty palms. It also makes people feel anxious and upset. This happens because the threat emotion systems in the brain have been triggered. If the threat persists, for example, if you are constantly being bullied every day, you may become very distressed, unhappy and depressed.

We then said that the same effect can also occur in response to threatening thoughts and images in our minds. So, if you are constantly being hard on yourself or being self-critical, your stress system will be activated triggering the emotional systems in your brain that make you feel low, anxious, or even angry. It will also have the effect of curbing positive feelings. Thus, for those people who tend to be self-critical, their threat systems are frequently being stimulated and they understandably feel more anxious, angry or depressed.

However, if when we make a mistake somebody is very kind and understanding towards us, this will help reduce feelings of stress or anxiety.  Therefore in the same way learning to generate compassionate images can help us feel calm, safe and soothed when we feel threatened.  Also, by thinking about what you want from your compassionate image it starts the “begins the process of gearing your mind to what you really need” (Gilbert & Choden, 2014, P. 242).

 

Varieties of compassion focused imagery

There are a huge number of varieties of compassion focused imagery.  During our sessions we’re going to focus on firstly developing a compassionate image and then using this to develop a more compassionate self.

 

 

Preparing for imagery

When you start to generate a compassionate image you may notice that your mind wanders away from the image.  This is totally normal and not a problem at all.  If you notice that your mind has wandered, gently and kindly bring your attention back to the image.  You may want to use your breath as an anchor during the practice.

You might also struggle to develop an image at all – that’s ok too, just remember it’s your intention to develop more compassion that’s important rather than the clarity of the image.

Acknowledgement:

The content of this booklet drew on the following resources:

Books

*Gilbert, P. (2009). The Compassionate Mind. Constable: London.

*Gilbert, P. (2010). Compassion Focused Therapy. Routledge: London, New York.

*Gilbert, P. (2010). An Introduction to the Theory and Practice of Compassion Focused Therapy and

Compassionate Mind Training for Shame Based Difficulties. Downloaded from

www.compassionatemind.co.uk/resources/training_materials.htm

*Gilbert, P. & Choden, P. (2014). Mindful Compassion: how the science of compassion can help you understand your emotions, live in the present, and connect deeply with others. New Harbinger Publications, Inc: Canada.

Welford, M. (2012). The Compassionate Mind Approach To Building Your Self-Confidence.

Robinson: London.

Articles

*Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment, 15, 199-208.

*Gilbert, P. (2010). An introduction to compassion focused therapy in cognitive behavior therapy. International Journal of Cognitive Therapy, 3, 97-112.

Appendix 13. Participant booklets

D. Session 4 Booklet

Creating a compassionate image

What do we mean by a compassionate image?

The compassionate image we are going to focus on is developing a ‘compassionate other’. There are many different terms to describe the ‘compassionate other’  – for example, Lee (2005) uses the term ‘perfect nurturer’ – this means that the image is perfect for us and looks to give us precisely what we might need.  Welford (2012) describes it as a ‘compassionate coach’. The term we use isn’t important, just chose wording that feels most comfortable for you.

 

The actual image that we develop will also be different for different people.  We will invite you to create and imagine your own ideal compassionate image.  Some people prefer to think about a non-human image such as images of nature e.g. sunlight, a warm sea, a tree or a mountain, or other non-human images such as an animal or an angel.  Other people may prefer to imagine a humanlike being, such as a very wise person.

As Gilbert & Choden (2014) explain, importantly, this image is completely focused on you and motivated by compassion to help you. The image knows how our brains can be quite tricky and how our early experiences can shape us. It helps you to feel understood. Your image is sensitive to your needs and feelings and has a deep desire to make you feel better.

Ultimately your compassionate image really wants you to be free from suffering

and to flourish in life! (Gilbert, 2010, p. 191)

 

The physical qualities of your compassionate image

 

The following questions may help you to create your compassionate image:

How would you like your compassionate image to look/appear – visual qualities/facial expressions/colour?

 

 

How would you like your compassionate image to sound (e.g., voice tone)?

 

 

 

What other sensory qualities would you like to give your compassionate image?

 

 

 

How would you like your compassionate image to relate to you?

 

 

 

How would like to relate to your compassionate image?

 

 

 

From Gilbert (2010, p. 190)

Qualities of your compassionate image

 

This exercise will help you start to build and develop your own compassionate image. It is important that you do your best to give your image specific qualities associated with compassion. These are described further below.  Think of these as “superhuman” – “complete and perfect compassionate qualities that never let you down” (Gilbert, 2010, p. 188). If at any point your image seems harsh or critical towards you, then refocus on these qualities.

  • A deep commitment to you – your compassionate image wants to help you manage with any difficulties that you might be experiencing, and ultimately experience more joy.
  • Wisdom – your compassionate image has wisdom which comes from understanding that we have to deal with a brain that we didn’t design and early experiences that we had no choice over.  Your compassionate image also knows you and your own life experiences so understands why you are the way you are.
  • Strength of mind – your compassionate image can hold and contain your pain and distress. It has the confidence and the strength to do this.
  • Warmth – your compassionate image expresses warmth by caring for you in a kind and gentle way.
  • Non-judgemental acceptance – your compassionate image is never harsh or critical about you or your experiences, it understands and accepts who you are.

Bringing the compassionate image to mind – a summary

  • Settle into a posture that feels comfortable to you

 

  • Bring your attention to the breath
  • Let images emerge in your mind

 

  • If nothing comes to mind or mind wanders, bring attention back to breath

 

  • Consider the specific qualities you would like your compassionate image to have

 

  • Consider what your compassionate image looks like or sounds like

 

  • Imagine that your compassionate image has the key specific qualities of commitment, wisdom, strength of mind, warmth and non-judgement

 

  • When you are ready, let your image fade, bring your attention back to your breath, and then ground yourself back into the room

 

 

Some ways of using your compassionate image

Imagine the voice of your compassionate image

As you develop your compassionate image, you might want to first focus on how it feels that your image cares about you in a kind and unconditional way.  You may then want to imagine your compassionate image looking at you with kindness and warmth and says this (or something similar) to you:

 

  • May you be well
  • May you be happy
  • May you be free of suffering

 

Generate compassionate-focused alternatives to self-critical thoughts

You may also want to use your compassionate image to help generate compassionate alternatives in response to self-critical thoughts.  For example, you can imagine what your compassionate image would say when you notice that you are being self-critical.

 

 

Compassionate other imagery longer script

Below is a copy of the script you would have gone through in your treatment session.  You could use it to read through again, or record yourself saying the words onto your phone.

Sitting posture

  • Begin by settling into a position that is comfortable for you – with your feet flat on the floor; if it’s ok sitting with your back supporting itself, away from the back of the chair; placing your hands on your lap; then allowing the eyes to either shut, or for your gaze to fall unfocused on the floor.
  • Embodying a position of wakefulness and dignity.
  • Then focus briefly on your facial expression – if you can, relax your facial muscles and then turn your mouth upwards slightly, into a slight smile – try to create a facial expression that is gentle and friendly. 

 

Rationale

  • The aim of this exercise is to develop a compassionate other image – an image that you can work with and develop with time.
  • Throughout the practice we will imagine receiving love and care from our compassionate other, so try to remember that your image really wants you to be free of suffering and flourish in life.
  • However, we may find it hard to develop or keep a clear image in mind, or we may find it hard to create feelings of warmth of kindness – and that’s ok – this exercise is not about visual clarity of an image, but is about developing “the wish” or the intention to be compassionate towards ourselves.

 

Notice the breath

  • Now, when you are ready, just begin to notice your breath.
  • Each in breath, as air comes into the body.
  • And each out breath, as air leaves the body.
  • You may want to do some deep abdominal breaths
  • Or you may want to develop what is called “soothing breathing rhythm” (Gilbert*) – where you breathe slightly more slowly and deeply than normal.  To do this, you may want to try breathing a little faster and the a little slower until you find a pattern or rhythm of breathing that is gentle and comfortable and gives you the feeling of slowing down.

Mind wandering

  • When you start to generate a compassionate image you may notice that your mind wanders away from the image.  This is totally normal and not a problem at all.  If you notice that your mind has wandered, gently and kindly bring your attention back to the image. 
  • Or you may want to use your breath as an anchor during the practice – so if your mind wanders, gently and kindly bring your attention to your breath for a moment before returning to the image. 

 

Compassionate other

  • So now let’s begin by focusing on what your compassionate image would look like
  • You may want to imagine your image coming out of a mist and then stands in front of you.
  • Or you may want to imagine your image as it walks slowly towards you.

 

Physical qualities of the compassionate other

  • What does your compassionate image look like? If they are human are they a man or a woman? Are they old or are they young? What is their facial expression like? If they are non-human what form do they take – an animal or an angel? Or an image of nature such as sunlight, a warm sea, a tree or a mountain? Or maybe a simply a bright light?
  • What colours are associated with your image?
  • What does your compassionate image sound like?  If it was to talk with you, what would it sound like? What tone of voice would it have?
  • With these questions in mind, spend a few moments imagining your compassionate other.

Specific compassionate qualities of the compassionate other

  • The image is your creation and so it embodies whatever you would like from feeling cared for.
  • As well as this, it’s important that you try to give your image specific qualities associated with compassion.
  • Think of these as “superhuman” – “complete and perfect compassionate qualities that never let you down” (Gilbert, 2010, P. 188).
  • If at any point your image seems critical, then refocus on creating these qualities.

 

  • Imagine that your compassionate image has a deep commitment to you – it wants to help you manage with any difficulties that you might be experiencing, and ultimately experience more joy. No matter what you say or do, your image is committed to supporting you.  It gives support and kindness to you always.  Spend a few moments imagining this commitment your image has for you.
  • Now focus on wisdom – your compassionate image has wisdom which comes from understanding that we have to deal with a brain that we didn’t design and early experiences that we had no choice over.  Your image also knows us and our own life experiences so truly understands why we are the way we are.  It understands your hopes and fears and offers you wisdom.  Spend a few moments imagining being in the presence of this wisdom.
  • Your compassionate image has strength of mind – it can hold and contain your pain and distress. It has the confidence the strength to do this.  Spend a few moments imagining being with this image.
  • Now focus on warmth – your compassionate image expresses warmth by caring for us in a kind and gentle way.  Spend a few moments imagining the warmth and affectionate feelings while with this image.
  • Finally, think about the quality of non-judgemental acceptance – your compassionate image is never harsh or critical about you or your experiences; it understands and accepts who you are.  Spend a few moments imagining this.

Speaking to you

  • Now, if you would like, imagine your compassionate image looking at you with warmth, understanding and kindness.
  • Imagine them saying:

 

  • May you be well
  • May you be happy
  • May you be free of suffering

 

In the last few moments, imagine that you are with your compassionate image.  Imagine that your image truly wants you to be well, happy and at peace. 

 

Then, let your compassionate image fade, and bring your attention back to your breathing.  When you are ready, open your eyes, and spend a few moments bringing yourself back into the room.

Problems with Compassionate Imagery

 

No clear image: It is rare to be able to generate a clear, sharp image. Images are usually fleeting and impressionistic. Getting a ‘sense of’ an image is good enough. Notice if there are any other sensory qualities. The quality of the image is not important but rather the feelings associated with it. You can also have more than one image that changes over time.

Image of a known person: Images of people we know may have unwanted associations, therefore, it is more helpful to create a unique compassionate image for yourself. Your image doesn’t even have to be a person, so long as it represents the qualities of strength, warmth and wisdom.

Critical voice: Some people notice their inner critic tells them their image is “not good enough” or “this is stupid”.  See if you can be mindful of this critical voice and focus on non-judgement.

Fear of Compassion:  Compassion may feel frightening or be associated with other unpleasant feelings. This may be because people have had negative experiences of being cared for or of feeling warmth and kindness.

Anger/Frustration: Developing compassion for oneself can also bring up feelings of anger, fear of anger and vengeful fantasies. Being self-compassionate is not about getting rid of anger but rather learning how to cope with it. It may require courage to face up to our anger.

Self-compassionate imagery is one of many ways of reducing self-critical thinking.  Sometimes we may find another strategy more helpful to help manage the self-criticism.  We might describe all of these strategies being part of our ‘toolbox’, and we can pick which strategy to use in different situations.

Acknowledgement:

The content of this booklet drew on the following resources:

Books

*Gilbert, P. (2009). The Compassionate Mind. Constable: London.

*Gilbert, P. (2010). Compassion Focused Therapy. Routledge: London, New York.

*Gilbert, P. (2010). An Introduction to the Theory and Practice of Compassion Focused Therapy and

Compassionate Mind Training for Shame Based Difficulties. Downloaded from

www.compassionatemind.co.uk/resources/training_materials.htm

*Gilbert, P. & Choden, P. (2014). Mindful Compassion: how the science of compassion can help you understand your emotions, live in the present, and connect deeply with others. New Harbinger Publications, Inc: Canada.

Welford, M. (2012). The Compassionate Mind Approach To Building Your Self-Confidence.

Robinson: London.

Articles

*Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment, 15, 199-208.

*Gilbert, P. (2010). An introduction to compassion focused therapy in cognitive behavior therapy. International Journal of Cognitive Therapy, 3, 97-112.

Other

Lee, D. A. (2005). The perfect nurturer: A model to develop a compassionate mind within the context of cognitive therapy. In Gilbert, Paul (Ed), (2005). Compassion: Conceptualisations, research and use in psychotherapy. (pp. 326-351). New York, NY, US: Routledge.

Appendix 13. Participant booklets

E. Session 5 Booklet

The Compassionate Self

In order to develop the compassionate self we first need to decide that this is something we want to cultivate.  We then need to practice becoming this person.  This is true for whatever part of the self that we want to develop.  For example, if someone wants to become a musician they will practice playing an instrument or if someone wants to be a tennis player they will practice playing the game.  Ask yourself, “what or who do I want to become?”  The way our brains our designed, we have the potential to form many different sides or parts of the ‘self’. Developing the compassionate self can help us to recognise all these different parts and respond to them with kindness and understanding.

So far we have used the thought record and the Compassionate Other to develop compassionate thinking.  This booklet describes other ways to develop the compassionate self by focusing on compassionate feelings and behaviours.

Remember the four key qualities of self-compassion are: wisdom, strength, warmth and non-judgment.

 

Accessing and developing the Compassionate Self

Method acting

One way to develop the compassionate self is to think about it like being an actor. In order to get into a particular role an actor needs to immerse him/herself in the way that they imagine the character thinks, feels and acts.  They would try and create certain feelings, thoughts and motives within themselves.  They would try to be that person.  They might consider the character’s tone of voice, posture, the kinds of things they say or the way they say them.  So now, imagine that the character you want to play is your ideal compassionate self. Using your ‘My Compassionate Self: A summary’ (beginning of this booklet) to remind you of the qualities you are aiming for, practice acting in this way.

 

Accessing and Developing your Compassionate Self

In this exercise you are going to spend some time accessing your Compassionate Mind and working on developing your compassionate self. You will bring to mind all aspects of your compassionate self, including how you might think, feel and behave. We have seen during the past sessions that you are able to access self-compassionate responses so the Compassionate Mind is already part of you, and we are now focused on accessing it and developing it further.  This may feel strange and difficult at first  but it may help to think about it like ‘method acting’ – to get into a role an actor would try to immerse themselves in that role, and try and actually create the associated thoughts, feelings and behaviours within themselves, and try to be that person. I will guide you through this and prompt you to access your compassionate mind and develop your compassionate self.

 

Sitting posture, facial expression and breathing

  • Begin by settling into a position that is comfortable for you – with your feet flat on the floor; if it’s ok sitting with your back supporting itself, away from the back of the chair; placing your hands on your lap; then allowing the eyes to either shut, or for your gaze to fall unfocused on the floor.
  • Then focus briefly on your facial expression – if you can, relax your facial muscles and then turn your mouth upwards slightly, into a slight smile – try to create a facial expression that is gentle and friendly. 
  • Now, when you are ready, begin to notice your breath. Notice each in-breath, as air comes into the body. And notice each out-breath, as air leaves the body.
  • Take a few moments just breathing and settling into this position.

 

 

Your Compassionate Self

  • When you are ready, set the intention that you would like to access your Compassionate Mind and that you would like to develop this further so that it becomes strong and easier to tap into. It does not matter if you cannot easily imagine your compassionate self, just setting the intention to do so will help.

 

 

  • Bring to mind your current self-compassionate qualities and others that you would ideally have as your compassionate self and spend some time with each.

 

Compassionate Qualities

  • In addition to your own personal compassionate attributes that we’ll talk about, you may wish to bring the mind the following compassionate qualities. If it feels difficult to access those qualities, it’s fine to gently and playfully imagine that you have these qualities.
    • Focus on the quality of kindness and warmth and a desire to be supportive.
    • Being sensitive and being able to tolerate difficulties.
    • Focus on the quality of wisdom. Yourself as a thoughtful, reflective and wise person who has learnt from your experience in the world.
    • Other important qualities for compassion are confidence, authority and maturity.
    • Being non-judgemental but also wanting to relieve suffering and produce change.
    • Compassion also includes generosity, concern and helpfulness.
  • Spend a few moments getting in touch with and developing your compassionate self. Notice what comes up for you.

 

My compassionate attributes

  • Now reflect on the following questions:
    • What attitude do you hold for yourself as a deeply compassionate person?
    • What compassionate thoughts do you have? What is your thinking style? What kinds of things do you say to yourself?
    • What compassionate feelings do you have?
    • If you were to feel distressed or experience difficult emotions, what is your compassionate approach? How would you treat yourself?
    • As your compassionate self, how do you behave? What kinds of behavioural intentions do you have?
    • What sensations do you notice in your body as your compassionate self?

 

Closing

  • With all of these compassionate qualities and attributes in mind imagine looking at yourself from the outside. See your facial expression, your posture and how you move in the world. Notice how you speak to others and your tone of voice. See how others relate to you as a compassionate person in the world.
  • You have a sense of the type of mind and self you would like to develop further – the more you practice the more easily you will be able to access these qualities and the more easily they will be able to express themselves through you.

 

  • Now, after spending a few last moments being your compassionate self, bring your attention back to your breathing. 
  • When you are ready, open your eyes, and spend a few moments bringing yourself back into the room.

 

You can use the results of this exercise to help complete the Compassionate Self Summary sheet on the next page.

It does not matter if you feel that you have these qualities or not, just imagining that you do will help.  Gilbert speaks about ‘compassion under the duvet’ and suggests that a good time practice developing your compassionate self is when you wake up in the morning. You could experiment with different times of day to work on this.  All you need to do is focus on your desire to be more compassionate and remember that you do have the capacity for strength and wisdom inside you.

This summary form will help you define what your compassionate self looks like in terms of the way you think, feel and behave.

My Compassionate Self: A summary

Compassionate attitude towards myself

 

 

Compassionate thoughts and thinking styles

 

 

Compassionate feelings towards myself

 

 

Compassionate approach to my distress or difficult emotions

 

 

My compassionate behaviours

 

 

Compassionate sensations in my body

 

 

 

 

Compassionate Feelings

Our emotions make themselves known very quickly and can seem very powerful, even making us behave in certain ways.  The emotions of anger and anxiety are directly linked with the threat-protection system and although they feel very unpleasant at times, we do not wish to condemn these emotions or aim to rid ourselves of them.  Instead, the compassionate approach is about approaching these emotions with an open and accepting mindset so that we may learn to tolerate and work with them.  The compassionate approach to difficult feelings such as anger, anxiety and disappointment is to accept these feelings as understandable responses to something that has threatened you.  These feelings are all part of the human experience and are not something that we choose to feel, however, we recognise that underneath them the self-protection system is kicking into action and doing its best to make you feel safe again.

For people who are very self-critical, developing a sense of compassion towards this side of them may bring about a realisation that this is a part of them that is really very frightened.  Some people may experience a sense of loss or grief as they direct compassion towards their self-criticism. This is because self-criticism often develops in an attempt to feel loved and included and it can move us to recognise how hard this has been for us.  You might feel sad as you acknowledge all the little hurts and disappointments you have experienced.  If this makes it seem like it is too much to bring compassion to this part of yourself, you don’t have to give up all your self-criticism but you can set the intention of moving towards a more compassionate way of being.

 

Loving-kindness practice

There is a basic Buddhist meditation that involves sending compassionate good wishes towards others and oneself.  Sometimes this is known as ‘loving-kindness’ or “metta bhavana” meditation.  One wishes for yourself and others to prosper and be happy. One can also extend this to all living things in steps.  This has been used in a lot of research studies (see website www.compassionatemind.co.uk for details) – with good evidence of brain and other changes. Many people find that it helps them to feel more kindly towards themselves and other people.

There are lots of different variations of loving-kindness meditations, many of which you can find on the Internet E.g.

There is also an app called ‘The Mindfulness App’ (£1.49 to download) which has a variety of different meditation exercises.

Alternatively there is an example script below, but it is important that you adjust this so that it feels right for you.  For example you may prefer to use words such as ‘peaceful and ‘happy’ instead of ‘calm and content’.

May you be safe from harm

May you be as strong and healthy as is possible for you

May you be calm and content

May I be safe from harm

May I be as strong and healthy as is possible for me

May I be calm and content

May we be safe from harm

May we be as strong and healthy as is possible for us

May we be calm and content

 

Compassionate Behaviour

As actions speak louder than words, to be fully compassionate you need to translate your compassionate intentions into actions.  Compassionate behaviour may require considerable courage and may involve learning to resist the desires of the old-brain.  For example, it may seem like we are being kind to ourselves by sitting in front of the television and eating ice-cream but this may not be the best action for us if we learn to live a sedentary and unhealthy lifestyle.  Self-compassion may involve saying ‘no’ to our desires and facing the disappointment that brings. Compassionate behaviour is not about being indulgent and succumbing to all our desires and fantasies.  It is about protection and doing what’s best for ourselves and others.

One way to think about compassionate behaviour is to imagine a young child who is refusing to go to bed and is demanding to watch more television.  As the child becomes more and more disruptive the parents of the child may find it very hard to say ‘no’ to their child and may be tempted to give in for an easier more peaceful evening.  This may be even harder if they are feeling guilty about being home late and not spending much time with their child that day.  It requires a lot of courage for a parent in this type of situation to stand true to their beliefs about what is in their child’s best interests and not to act out of guilt or frustration.

In order to behave in a compassionate way we first need to recognise that there is a problem.  For example, if someone is bullying you and this is causing you distress, the compassionate thing to do would be take some form of action.  This may mean removing yourself from the situation or it may mean facing the bully; either way you will be addressing the problem head-on rather than avoiding it.

In the same way it takes courage to stand up to a bully in our environment, it also takes courage to recognise when you are your own bully.  Consider the next few sections to be a toolbox of compassionate behaviours and techniques that may help you to stand up to your self-critic.

Remember that no-one can behave in an ideal or self-compassionate manner all the time. It is important to bring self-compassion to those times when we behave in ways that we are less than ideal!

 

 

 

 

 

 

 

 

 

 

 

 

Avoidance

Self-critical thinking can often be associated with avoidant behaviours. There are many different types of avoidance. Common examples include:

  • Procrastination over work
  • Avoiding social situations that make us feel anxious, e.g. being with certain people, interviews, public speaking
  • Avoiding other situations that make us feel anxious
  • Avoiding expressing our opinions, feelings, preferences or needs
  • Avoiding making decisions or taking responsibility

Although these behaviours may make us avoid perceived threat in the short-term, they can all have longer-term disadvantages. They can also fuel further self-criticism.

 

Over-controlled behaviours

Some of us try to deal with perceived threat by trying hard to control things. Examples of forms of attempts to control:

  • Over-planning how we will cope with situations
  • Over-preparing our work
  • Perfectionist behaviours in relation to work, our diet, exercise, appearance etc.
  • Over-thinking situations beforehand or afterwards

Such behaviours can help us to feel safe and may be very reinforcing if they seem to help us to avoid negative situations or outcomes. However, they often have unintended consequences. For example they can be very time-consuming so we miss out on other things. They can make us inflexible which other people can find difficult. We can become irritated if other people don’t fit in with our plans. Over-thinking before a situation has happened can make us feel more anxious as we remain focused on a potential negative outcome that we are trying to avoid. Over-analysing a situation afterwards can also make us feel more anxious or low. Sometimes we try so hard that our attempts can backfire and cause new problems that we hadn’t intended!

 

Reducing avoidant or over-controlled behaviours

If you want to try to reduce an avoidant or over-controlled behaviour, it can be helpful to plan specify ways of testing out new ways of doing things. Some people find it helpful to do this gradually in small steps. Others prefer to throw themselves in at the deep end and be open to learning from what happens in a self-compassionate manner

Show your feelings

People who are very self-critical often report that they find it difficult to express their opinions and needs to others.  Remember that you have a right to your own values, opinions and feelings.  Feelings are normal and helpful, even negative or difficult ones.  An important role of emotions is the signals they send to oneself and to others.  Therefore, these emotions are most useful when shared with others – when they can communicate our feelings and state of mind to others.  Try not to suppress or hide your feelings – let them show in a useful way.  Expressing feelings to other people, whether directly or in writing tends to make us feel better.

 

Be assertive

  • Be specific – say how your feel or what you want specifically / directly
  • Work out what the issues are rather than labelling or attacking the person or oneself
  • Own the problem.  A problem is yours whenever you are the person whose needs are not being met. By clearly telling others “I have a problem”, you lessen the chance that they will become defensive and increase the chance of resolving the conflict.
  • If requesting change, briefly describe one behaviour is troubling you, and your feelings about the behaviour and its consequences: The formula is:  “I have a problem. When you [describe the behaviour], [state the consequences] and I feel [describe your feelings].  For example: “I have a problem.  When you drive so fast on this winding road, you put us in danger of going over the side and I feel afraid”.
  • Aim for a workable compromise – assertiveness is not about winning, you need to find a true compromise that takes both parties’ needs into consideration
  • If necessary, repeat in a calm manner – this can help you from getting distracted
  • Anger at our own lack of assertiveness is common.  This self-directed anger can be more damaging to us than the lack of assertiveness.

 

Make small behaviour changes

Try out a range of new behaviours over time rather than picking one new behaviour and sticking to it rigidly.  This prevents you from becoming bored as you habituate to the new behaviour.  Aim to incorporate these changes into your daily life and you will be taking positive action in your life.

 

Compassionate health behaviours

Research has shown that doing regular exercise can have a positive effect on our mood.  Exercise is associated with release of endogenous opiates, and consequently is thought to improve mood.  Note that if you tend to push yourself too hard with regards to exercise e.g. exercising strenuously every day and finding it difficult to have a day off, then a more self-compassionate approach may be to reduce the amount or intensity of exercise and ensure that you have days off to allow your body time to rest and repair. Similarly, being self-compassionate means taking a balanced and self-supportive approach to other health-related behaviours such as eating, drinking, drugs and sexual health. Either extreme – excessive or over-controlled behaviours – can have unintended adverse consequences.

 

 

 

Guiding your day with self-compassion

Here is another exercise to help you cultivate your Compassionate Self:

Step 1: Take a breath to settle your mind and body

 

Step 2: Imagine your compassionate self or compassionate ideal

 

Step 3: With warmth, ask your compassionate self or compassionate ideal “what can I do for myself today that will make it a better day?”

 

Step 4: Remind yourself of your self-compassionate attitudes e.g. “I treat myself with kindness and respect; I look after my own needs (physical, psychological, social, spiritual etc)”

or

Make a positive statement about today e.g. “I will treat myself with kindness and respect, I will attend to my own needs”

 

Step 4: Imagine how you will feel if you do the things you brought to mind in the previous step

 

Step 5: Take a breath and notice how you feel

 

Step 6: Be guided by your compassionate advice

 

 

 

 

 

 

Acknowledgement:

The content of this booklet drew on the following resources:

 

Books

*Gilbert, P. (2009). The Compassionate Mind. Constable: London.

*Gilbert, P. (2010). Compassion Focused Therapy. Routledge: London, New York.

*Gilbert, P. (2010). An Introduction to the Theory and Practice of Compassion Focused Therapy and

Compassionate Mind Training for Shame Based Difficulties. Downloaded from

www.compassionatemind.co.uk/resources/training_materials.htm

*Gilbert, P. & Choden, P. (2014). Mindful Compassion: how the science of compassion can help you understand your emotions, live in the present, and connect deeply with others. New Harbinger Publications, Inc: Canada.

Welford, M. (2012). The Compassionate Mind Approach To Building Your Self-Confidence.

Robinson: London.

Articles

*Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment, 15, 199-208.

*Gilbert, P. (2010). An introduction to compassion focused therapy in cognitive behavior therapy. International Journal of Cognitive Therapy, 3, 97-112.

Appendix 15. Post-intervention ratings of how useful participants found the intervention

Feedback question Strongly disagree,

n (%)

Disagree,

 n (%)

Neither agree or disagree,

n (%)

Agree,

n (%)

Strongly agree,

n (%)

Mean Standard deviation
The intervention was useful 0 0 0 9

(42.9)

12

(57.1)

4.6 0.49
The intervention helped to reduce my self-critical thinking 0 0 2

(9.5)

10

(47.6)

9

(42.9)

4.3 0.64
The intervention helped improve my ability to cope with my self-critical thinking 0 0 1

(4.8)

10

(47.6)

10

(47.6)

4.4 0.58
The intervention helped me to improve my self-compassion 0 1

(4.8)

3

(14.3)

9

(42.9)

8

(38.1)

4.1 0.83
My facilitator understood my needs/ difficulties 0 0 2

(9.5)

6

(28.6)

13

(61.9)

4.5 0.66
I would recommend the intervention to other people with high levels of self-criticism 0 0 0 7

(33.3)

14

(66.6)

4.7 0.47

 

Notes: participants rated their agreement on a 5-point Likert scale: strongly disagree = 1; disagree =2; neither agree or disagree = 3; agree = 4; strongly agree = 5

Appendix 16. Post-intervention ratings of how useful participants found each technique

Technique Not at all,

n (%)

A little,

n (%)

Somewhat,

n (%)

Quite a lot,

n (%)

Very much,

n (%)

N/A – didn’t try at all,

n (%)

Mean Standard deviation
Compassionate reframe 0 3

(14.3)

2

(9.5)

8

(38.1)

8

(38.1)

0 3 1.02
Decentering 1

(4.8)

2

(9.5)

2

(9.5)

4

(19.0)

12

(57.1)

0 3.1 1.21
Changing the context 1

(4.8)

4

(19.0)

2

(9.5)

8

(38.1)

6

(28.6)

0 2.7 1.21
Relaxation exercises 0 4

(19.0)

9

(42.9)

0 8

(38.1)

0 2.6 1.18
Compassionate other imagery 3

(14.3)

4

(19.0)

3

(14.3)

5

(23.8)

6

(28.6)

0 2.3 1.43
Loving-kindness meditation 0 3

(14.3)

4

(19.0)

4

(19.0)

7

(33.3)

3

(14.3)

2.8 1.12
The compassionate self 2

(9.5)

4

(19.0)

2

(9.5)

3

(14.3)

7

(33.3)

3

(14.3)

2.5 1.46
Compassionate behaviours 1

(4.8)

4

(19.0)

4

(19.0)

5

(23.8)

4

(19.0)

3

(14.3)

2.4 1.21

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes: participants rated their agreement on a 5-point Likert scale: not at all = 0; a little = 1; somewhat = 2; quite a lot = 3; very much = 4

Appendix 17. Ratings of frequency of use for each technique since end of treatment collected at follow-up appointment

Technique Not at all,

n (%)

Once or twice,

n (%)

Several times,

n (%)

Once a week,

n (%)

Several times a week,

n (%)

Everyday,

n (%)

Mean Standard deviation
Compassionate reframe 1

(4.5)

1

(4.5)

7

(31.8)

3

(13.6)

8

(36.6)

2

(9.1)

3 1.28
Decentering 4

(18.2)

0 3

(13.6)

5

(22.7)

2

(9.1)

8

(36.6)

3.1 1.82
Changing the context 7

(31.8)

4

(18.2)

3

(13.6)

2

(9.1)

2

(9.1)

4

(18.2)

2 1.88
Abdominal breathing 5

(22.7)

4

(18.2)

2

(9.1)

3

(13.6)

6

(27.3)

2

(9.1)

2 1.88
Progressive muscle relaxation 11

(50)

1

(4.5)

2

(9.1)

3

(13.6)

3

(13.6)

2

(9.1)

1.6 1.85
Compassionate other imagery 7

(31.8)

6

(27.3)

4

(18.2)

1

(4.5)

2

(9.1)

2

(9.1)

1.6 1.61
The compassionate self 9

(40.9)

4

(18.2)

2

(9.1)

2

(9.1)

4

(18.2)

1

(4.5)

0.6 1.19
Guiding your day with self-compassion 11

(50)

0 2

(9.1)

2

(9.1)

2

(9.1)

5

(22.7)

1.6 1.70
Loving-kindness meditation 16

(72.7)

2

(9.1)

3

(13.6)

0 0 1

(4.5)

2 2.12
Compassionate behaviours 7

(31.8)

0 0 3

(13.6)

7

(31.8)

5

(22.7)

2.8 2.01

 

 

Notes: participants rated their agreement on a 6-point Likert scale: not at all = 0; once or twice = 1; several times = 2; once a week = 3; several times a week = 4; every day = 5

Appendix 18. Results of independent t-tests comparing the two therapists on participant measures across time points

Measure Time point t (21) p-value
Habitual Index of Negative Thinking (HINT) Screening .24 .81
Pre-intervention .40 .69
Post-intervention -.26 .80
Follow-up .38 .71
Self-Critical Rumination Scale (SCRS) Screening -.50 .62
Pre-intervention -1.02 .32
Post-intervention -1.51 .15
Follow-up -.50 .62
Work and Social Adjustment Scale (WASA) Screening -.62 .54
Pre-intervention -1.40 .18
Post-intervention -.19 .85
Follow-up .17 .86
Patient Health Questionnaire (PHQ-9) Screening 1.64 .12
Pre-intervention 0.04 .96
Post-intervention -0.05 .96
Follow-up 0.35 .73
Generalised Anxiety Disorder (GAD-7) Screening -.83 .42
Pre-intervention -1.04 .31
Post-intervention .30 .77
Follow-up -.84 .41
Rosenberg’s Self-Esteem Scale (RSES) Screening -1.28 .21
Pre-intervention -1.10 .28
Post-intervention 0.52 .61
Rosenberg’s Self-Esteem Scale (RSES) Follow-up -0.03 .98
Multi-Dimensional Perfectionism Scale (MDPS) Pre-intervention -.23 .82
Post-intervention -1.14 .27
Follow-up -.09 .93
Self-compassion Scale (SCS) Pre-intervention -.01 .99
Post-intervention .06 .95
Follow-up .59 .56
Emotion Regulation Questionnaire – Regulation Pre-intervention -.02 .99
Post-intervention .32 .75
Follow-up .38 .71
Emotion Regulation Questionnaire – Suppression Post-intervention -2.18 .04
Follow-up -1.25 .22
Beliefs about Emotions Scale (BES) Pre-intervention -1.46 .16
Post-intervention -2.25 .04
Follow-up -1.38 .18

 

 

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

Dependent variable (i) Independent variable F value (1, 21) p value
HINT-change Length of baseline .02 .90
Time from screening to post-intervention .01 .94
Time from pre to post-intervention .42 .53
SCRS-change Length of baseline .24 .63
Time from screening to post-intervention .13 .72
Time from pre to post-intervention .27 .61
WASAS-change Length of baseline 3.25 .09
Time from screening to post-intervention 2.08 .16
Time from pre to post-intervention 1.90 .18
PHQ-9-change Length of baseline 3.02 .10
Time from screening to post-intervention 2.80 .11
Time from pre to post-intervention .30 .59
GAD-7-change Length of baseline .66 .43
Time from screening to post-intervention .75 .40
Time from pre to post-intervention .00 .98
RSES-change Length of baseline .06 .80
Time from screening to post-intervention .04 .85
Time from pre to post-intervention .05 .83
MDPS-change Length of baseline .20 .66
Time from screening to post-intervention 1.15 .30
Time from pre to post-intervention 3.51 .08
SCS-change Length of baseline .33 .57
Time from screening to post-intervention 1.35 .26
Time from pre to post-intervention 2.85 .11
ERQ-R-change Length of baseline 1.57 .22
Time from screening to post-intervention 2.48 .13
Time from pre to post-intervention .34 .57
ERQ-S-change Length of baseline .78 .39
Time from screening to post-intervention .08 .78
Time from pre to post-intervention 5.02 .04
BES-change Length of baseline .08 .78
Time from screening to post-intervention .50 .49
Time from pre to post-intervention 1.61 .22

Notes: (i) Dependent variable computed by: post-intervention scores minus pre-intervention scores; HINT: The Habitual Index of Negative Thinking; SCRS: Self-Critical Rumination Scale; WASAS: Work and Social Adjustment Scale; PHQ-9: Patient Health Questionnaire; GAD-7: Generalised Anxiety Disorder; RSES: Rosenberg Self-Esteem Scale; MDPS: Multi-Dimensional Perfectionism Scale; SCS: Self-Compassion Scale; ERQ-R: Emotion Regulation Questionnaire-Reappraisal; ERQ-S: Emotion Regulation Questionnaire-Suppression; BES: Beliefs about Emotions Scale

Appendix 20. Line graphs for secondary outcome measures (PHQ-9, GAD-7, RSES and ‘maladaptive perfectionism) at main study time points

Line graph to show mean scores for the Patient Health Questionnaire (PHQ-9) at screening, pre-intervention, post-intervention & follow-up (one standard deviation error bars)

Line graph to show mean scores for the Generalised Anxiety Disorder (GAD-7) at screening, pre-intervention, post-intervention & follow-up (one standard deviation error bars)

Line graph to show mean scores for the Rosenberg’s Self-Esteem Scale (RSES) at screening, pre-intervention, post-intervention & follow-up (one standard deviation error bars)

Line graph to show mean scores for ‘maladaptive’ perfectionism at pre-intervention, post-intervention & follow-up (one standard deviation error bars)

Appendix 21. Line graphs for process measures (SCS, ERQ-reappraisal, ERQ-suppression, and BES) at main study points

 

Line graph to show mean scores for the Self-Compassion Scale (SCS) at pre-intervention, post-intervention & follow-up (one standard deviation error bars)

Line graph to show mean scores for the Emotion Regulation Scale (ERQ) Reappraisal at pre-intervention, post-intervention & follow-up (one standard deviation error bars)

Line graph to show mean scores for the Emotion Regulation Scale (ERQ) Suppression at pre-intervention, post-intervention & follow-up (one standard deviation error bars)

Line graph to show mean scores for the Beliefs about Emotions Scale (BES) at pre-intervention, post-intervention & follow-up (one standard deviation error bars)

Systematic Review

 

 

 

Self-criticism self-report measures: Systematic Review

 

 

 

 

 

 

 

 

 

 

 

 

 

First supervisor: Dr Katharine Rimes

Second supervisor: Dr Patrick Smith

Contents

Abstract………………………………………………………

1. Introduction………………………………………………….

1.1 Self-criticism……………………………………………..

1.2 Measures of self-criticism……………………………………..

1.3 Rationale of current systematic review…………………………….

2. Objective……………………………………………………

3. Method…………………………………………………….

3.1 Search strategy……………………………………………

3.2 Search terms……………………………………………..

3.3 Selection criteria…………………………………………..

3.5 Selection process…………………………………………..

3.6 Data extraction……………………………………………

3.7 Quality assessment…………………………………………

3.7.1 Step one – assessment of the methodological quality of studies………….

3.7.2 Step two – quality assessment of instruments……………………..

3.7.3 Step three – Best Evidence Synthesis (BES)……………………….

3.8 Measurement properties……………………………………..

3.8.1 Measurement properties in this study………………………….

4. Results……………………………………………………..

4.1 Selection of studies…………………………………………

4.2 Questionnaires found in search………………………………….

4.3 Self-criticism as a trait……………………………………….

4.3.1 Self-Critical Cognition Scale (SCCS)…………………………….

Reliability………………………………………………

Validity………………………………………………..

Best Evidence Synthesis (BES)………………………………….

4.3.2 Levels of Self-Criticism Scale (LSCS)…………………………….

Reliability………………………………………………

Validity………………………………………………..

Best Evidence Synthesis (BES)………………………………….

4.3.3 Attitudes Towards Self Scale (ATSS)……………………………

Reliability………………………………………………

Validity………………………………………………..

Best Evidence Synthesis (BES)………………………………….

4.3.4 Attitudes Towards Self Scale-Revised (ATSR)………………………

Reliability………………………………………………

Validity………………………………………………..

Best Evidence Synthesis (BES)………………………………….

4.3.5 Temperament & Personality Questionnaire (TPQ)…………………..

Reliability………………………………………………

Validity………………………………………………..

Best Evidence Synthesis (BES)………………………………….

4.4 Self-criticism in response to difficult situations……………………….

4.4.1 Forms of Self-Criticising/Attaching and Self-Reassuring Scale (FSCRS)………

Reliability………………………………………………

Validity………………………………………………..

Best Evidence Synthesis (BES)………………………………….

4.4.2 Self-Compassion Scale (SCS)…………………………………

Reliability………………………………………………

Validity………………………………………………..

Best Evidence Synthesis (BES)………………………………….

4.5 Self-criticism as a mood regulation strategy………………………….

4.5.1 Inventory of Cognitive Affect Regulation Strategies (ICARUS)……………

Reliability………………………………………………

Validity………………………………………………..

Best Evidence Synthesis (BES)………………………………….

4.6 Measures of repetitive self-criticism………………………………

4.6.1 Habit Index of Negative Thinking (HINT)…………………………

Reliability………………………………………………

Validity………………………………………………..

Best Evidence Synthesis (BES)………………………………….

4.6.2 Self-Critical Rumination Scale (SCRS)……………………………

Reliability………………………………………………

Validity………………………………………………..

Best Evidence Synthesis (BES)………………………………….

5. Discussion…………………………………………………..

5.1 Self-criticism scales and subscales………………………………..

5.1.1 Self-criticism as a trait…………………………………….

5.1.2 Self-criticism in response to difficult situations…………………….

5.1.3 Self-criticism as a mood regulation strategy………………………

5.1.4 Measures of repetitive self-criticism……………………………

5.2 Assessing the methodological quality of included studies…………………

5.2.1 Issues with content validity…………………………………

5.2.2 Issues with reliability……………………………………..

5.2.3 A COSMIN ‘fair’ rating…………………………………….

5.2.4 Assessing face validity?……………………………………

5.3 Recommendations………………………………………….

5.4 Limitations………………………………………………

5.5 Conclusions………………………………………………

References…………………………………………………….

Appendices contents page…………………………………………..

Appendix 1. Table 2 Questionnaire Characteristics………………………..

Appendix 2. Table 3 Study Characteristics……………………………..

Appendix 3. Table 4 Quality criteria for measurement properties assessed………..

Appendix 4. Table 5 Ratings for methodological quality and measurement properties…

Appendix 5. Table 6 Construct validity – ratings for methodological quality and measurement property…..

List of Tables

Table 1 Best Evidence Synthesis (BES)

Appendix 1. Table 2 Questionnaire Characteristics

Appendix 2. Table 3 Study Characteristics

Appendix 3. Table 4 Quality criteria for measurement properties assessed

Appendix 4. Table 5 Ratings for methodological quality and measurement properties

Appendix 5. Table 6 Construct validity – ratings for methodological quality and measurement property

Abstract

Objectives

Self-criticism is a transdiagnostic process that has been attracting recent research and clinical interest. This systematic review identified and evaluated the measurement properties of self-report questionnaires of self-criticism.

Methods

A systematic review was performed using four databases and a search of the grey literature was undertaken. Studies were included when the main focus was to evaluate the measurement properties of English versions of scales or subscales that aimed to measure self-criticism in adults. Both the methodological quality of included studies and the specific measurement properties were evaluated; these ratings were then combined into a best evidence synthesis.

 

Results

Five scales and five subscales were identified, described in 14 papers. The scales were designed to measure different types of self-critical thinking including trait self-criticism, repetitive self-criticism and self-criticism in response to difficult situations or as a mood regulation strategy.  The majority of the included studies were either rated as having poor methodological quality, or were given indeterminate or negative ratings for the measurement properties they reported.

 

Conclusions

Only tentative recommendations could be made about two measures of self-criticism based on existing evidence; future high quality research is required.  Questionnaire choice should also include consideration of the type of self-criticism that the clinician or researcher wishes to assess.

1. Introduction

 

1.1 Self-criticism

Self-criticism has been defined as a self-evaluative process where individuals judge aspects of themselves in a negative or harsh way (Shahar et al., 2015a).  Experiencing self-criticism has been reported in the general population (Kupeli et al., 2013) and across a range of settings including sport (Anshel & Sutarso, 2010) and academia (Powers et al., 2011).  It is thought to be closely related to shame (Smart et al., 2015), as well with as lower levels of self-compassion (Neff, 2003).  A large amount of research has focused on its relationship with perfectionism; self-criticism is thought to be a central component of “perfectionistic concerns”, a negative form of perfectionism (Powers, Zuroff & Topciu, 2004; Bergman, Nyland & Burns, 2007).  Furthermore, it has been suggested that self-critical elements of perfectionism are key to the link between perfectionism and depression (Gilbert, Durrant & McEwan, 2006).

As expected, higher levels of self-criticism have been reported in clinical populations compared with non-clinical populations (Baiao et al., 2014).  Self-criticism is thought to be a transdiagnostic process as it has been associated with a number of different mental health problems. Previous research has particularly focused on its association with depression (Cox et al., 2004a; Luyten et al., 2007).  Dunkley et al (2009) found that self-criticism predicted symptoms of depression and global psychosocial impairment across a 4-year period.  Furthermore, self-criticism has been found to mediate the relationship between shame and depression (Pinto-Gouveia et al., 2013).

Self-critical individuals are also more likely to experience a range of other clinical difficulties including suicidality (O’Connor & Noyce, 2008), social anxiety (Cox, Fleet & Stein, 2004b; Shahar et al., 2015b), eating disorders (Fennig et al., 2008), compulsive exercise (Taranis & Meyer, 2010), binge eating disorder (Dunkley, Masheh & Grilo, 2010), Post-Traumatic Stress Disorder (Cox et al., 2004c; Harman & Lee, 2009) and persecutory delusions (Hutton et al., 2012).

In treatment studies, self-critical individuals have greater difficulties establishing and maintaining therapeutic relationships (Whelton, Paulson, & Marusiak, 2007), as well as worse therapeutic outcomes (Rector et al., 2000; Marshall et al., 2008).  As self-critical individuals appear to be vulnerable to a wide range of mental health problems, and possibly have difficulties engaging in treatment, research has also begun to focus on treatments specifically targeting self-criticism (see Kannan & Levitt, 2013 for a review, as well as Shahar et al., 2012; 2015a for example treatment studies).

 

1.2 Measures of self-criticism

Different research groups have conceptualised self-criticism in different ways. As a consequence, a number of self-report questionnaires measuring self-criticism have been developed.  These differ in terms of design, structure and content.  Some questionnaires are designed to measure self-criticism as a single factor whereas others assess different forms of self-criticism. A number of questionnaires have been developed that contain a subscale measuring self-criticism as one component of a broader construct such personality traits associated with depression (Parker et al., 2006) or self-compassion (Neff, 2003). Furthermore, as well as focusing on the content of self-critical thinking, measures have been developed that define self-criticism, or negative self-thinking, as a mental habit, with more of a focus on its process, in terms of frequency or repetitiveness, controllability and level of awareness (Verplanken et al., 2007).

As no ‘gold standard’ questionnaire has been identified, some researchers have also attempted to measure self-criticism by using a mixture of items taken from different measures (for example, Cox et al., 2004a), or used questionnaires that were not originally developed to measure self-criticism, such as the Dysfunctional Assumptions Scale (DAS) (Weissman & Beck, 1978) or the original or revised versions of the Depressive Experiences Questionnaire (DEQ) (Blatt, 1976; Welkowitz, Lish & Bond, 1985; Bagby et al., 1994; Viglione et al., 1995; Santor, Zuroff & Fielding, 1997).  Although the DEQ contains a factor called ‘self-criticism’, this factor aims to measure ‘introjective depression’, rather than the construct of self-criticism.

 

1.3 Rationale of current systematic review

The accurate measurement of clinical constructs with valid and reliable questionnaires is crucial.  Having multiple measures of self-criticism creates a number of difficulties for both researchers and clinicians, especially when it is unclear about which questionnaires are of adequate psychometric quality (de Boer et al., 2004). Firstly, it is difficult to choose an appropriate questionnaire to use in a research study.  This may be particularly problematic when wanting to use a questionnaire that has been validated in a non-clinical population with different patient groups. Secondly, if different measures are used, the comparison of results between research studies is very hard.  Finally, if researchers use questionnaires that were not originally designed to measure self-criticism, or select items from different measures, it may lead uncertainty about the interpretation of their findings and conclusions.

2. Objective

The purpose of this systematic review was to identify and evaluate the measurement properties of self-report questionnaires of self-criticism. The characteristics, for example, length, content area and response options, and psychometric properties are reviewed and recommendations about the potential clinical and research utility of the different measures are made. This systematic review therefore allows an evaluation of current measures of self-criticism, as well a direct comparison between these measures.  It is hoped that it will help both researchers and clinicians to make “evidence-based decisions” (Abma et al., 2012, P. 6) about which questionnaire is most appropriate for a particular context.

3. Method

 

3.1 Search strategy

OvidSP and Web of Science (WoS) were used to search through a number of databases.  In WoS, the Core collection & Medline were both selected, excluding case reports, and refined by English language. In OvidSP, PsycINFO, Ovid Medline (R) (1946 to date of search) and Embase Classic+Embase (1947 to date of search) were selected, with English language added as a limit. The initial search took place in June 2015 and the search was updated in February 2016.

In order to account for publication bias, an initial scope of some Grey literature databases were completed in June 2015 (Mahood, Van Eerd & Irvin, 2014). The initial grey literature search meant that the author was fairly certain that no relevant unpublished papers were being excluded; therefore only published articles were included in the review. The Grey literature search terms and databases are listed below:

Grey literature search terms:

“self criticism” AND psychometric

Grey literature databases:

3.2 Search terms

The search terms used were:

“self critic*” OR “inner critic*” OR “negative think*” OR “negative self statements” OR “self judg*” OR “self attitude*” OR “attitude* toward self”

AND

Psychometric* OR reliab* OR valid* OR reproducib* OR construct* OR develop* OR creat* OR assess*

The search terms related to self-criticism were chosen to maintain the specificity of this systematic review, but also included broader terms (for example “negative think”) to reduce the risk of excluding potentially relevant papers.  The use of broader search terms was also necessary because this systematic review included sub-scales of self-criticism and it was possible that authors may not have included all of the subscales names in the abstract. Of note, self-esteem was not included as a search term in this systematic review.  Although it could be argued that the degree of self-criticism may be associated with one’s level of self-esteem, this review considered them to be related but distinct constructs.

In relation to the psychometric search terms, a number of these were chosen from a previously developed search filter (Terwee et al., 2009). A scope of previous systematic reviews focused on psychometric properties was also completed which informed the decision to add in some additional search terms.  Furthermore, COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) recommends not using a search term for the “type of measurement instrument”, for example, questionnaire, inventory, scale, etc.  It suggests that, because of the wide range of terminology used to describe questionnaires, this increases the risk of some being inappropriately excluded (COSMIN, 2016A).

3.3 Selection criteria

The inclusion and exclusion criteria was as follows:

Inclusion

  1. Full text original article published in English in a peer reviewed journal;
  1. The main focus of the article was to describe the development or evaluation of the measurement properties of the self-report questionnaire (or interview-schedule);
  1. The mentioned self-report questionnaire aimed to measure self-criticism (or a synonym of self-criticism) (either the whole measure, or a sub-scale).
  1. The measure or subscale focused on self-criticism in a general way across different life domains (rather than focusing on self-criticism about one particular activity, for example, sport or education);
  1. The measure or subscale that was used was the English version the particular questionnaire;
  1. The article assesses the questionnaire using the adult population (either clinical or non-clinical);

Exclusion

  1. Studies assessing questionnaires of self-criticism with children, young people or more than one adult (for example, romantic couples);
  1. The items of the self-report questionnaire could not be extracted or located (after internet searches completed, inter-library loan requests made & authors directly contacted);
  1. Articles that focused on the psychometric properties of a questionnaire that had been translated into a different language;
  1. Opinions, reviews, editorials, conference summary posters & unpublished dissertations were also excluded.

The inclusion criteria is in line with the COSMIN guidelines that state that the focus of the study for inclusion in such a systematic review “should be the development or evaluation of the measurement properties of a measurement instrument” (COSMIN, 2016A). Focusing only on psychometric studies is also in line with a number of previous systematic reviews that have used COSMIN (for example, Abma et al., 2012; Weldam et al., 2013).

Of note, only English version of questionnaires were included; Schellingerhout et al (2012) point out that pooling results from original and translated versions of questionnaires could result in inconsistent findings.

3.5 Selection process

After the initial search, the references were exported into EndNote and then into Excel. The titles and abstracts were screened by the main author. After this, full texts were found through EndNote, OvidSP, inter-library loans, Senate House (a central library for the University of London) and by contacting the authors directly. Authors were also contacted if a copy of the questionnaire items were not included in the original development paper. At the full-text stage, where unclear, the inclusion / exclusion of particular questionnaires or studies were discussed further with the author’s supervisor. Reference checking and citation tracking (using OvidSP and Google Scholar) were then carried out on studies that met the inclusion criteria.

3.6 Data extraction

The following data was extracted from the included studies:

  1. Questionnaire characteristics;
  2. Study characteristics (as recommended by Mokkink et al (2012) this data was extracted through completing the Interpretability and Generalisability COSMIN boxes);
  3. Evaluated measurement properties of the questionnaires.

3.7 Quality assessment

The quality assessment was completed in three stages. To ensure that the included articles met the inclusion / exclusion criteria and the quality assessment was accurate, fivearticles were double rated by two independent reviewers, the main author and another trainee clinical psychologist who was familiar with COSMIN. The strength of agreement between reviewers was ‘very good’ [k= 0.88, p<0.0005] (Altman, 1999).

3.7.1 Step one – assessment of the methodological quality of studies

Before a questionnaire can be used, research should evaluate its measurement properties, and these studies should be of high methodological quality (Mokkink et al., 2010a). As Terwee et al (2012) point out, if the methodological quality of a study is adequate, their results can be deemed valid and appropriate conclusions can be made from them, i.e. it can truly assess whether the instrument is useful.  On the other hand, if the quality of a study is poor, it remains unclear what conclusions can be drawn from results.

The methodological quality of the included studies were assessed using COSMIN (Mokkink et al., 2010a) (a copy of the COSMIN checklist was retrieved online – see COSMIN, 2016B). COSMIN is the only specific tool focused on methodological quality assessment. The following domains are covered by COSMIN: internal consistency, reliability, measurement error, content validity, construct validity (divided into structural validity, hypothesis testing and cross-cultural validity), criterion validity and responsiveness. There are three additional boxes within COSMIN; the first is only completed if a study uses Item Response Theory (IRT) methods, an assessment method that takes both the item characteristics and participants personality abilities into account (An & Yung, 2014). The final two boxes focus on Interpretability, i.e. the degree to which one can interpret qualitative meaning from quantitative scores, and Generalisability, i.e. how generalizable the results of a study are.

COSMIN was completed using a 4-step procedure (Mokkink et al., 2012). In step 1, the author determined which properties were assessed in the specific study, and therefore which COSMIN boxes need to be completed. Sometimes, within one study the same measurement property had been assessed in multiple participant groups, or different participant groups had been used to assess different measurement properties; in both cases the relevant COSMIN boxes were completed more than once for that study. As pointed out by Mokkink et al (2012), this step required subjective judgement as studies used different terminology for measurement properties. In step 2, the author determined whether IRT methods had been used by the study and, if they had, the IRT box was completed. In step 3 and 4, the author completed the boxes that corresponded to those marked out in step 1, as well as the Interpretability and Generalisability box.

For each study or sample, the methodological quality for a particular measurement property was rated by a series of items on a 4-point nominal rating scale: poor, fair, good, and excellent (Terwee et al., 2012). For each measurement property, an overall score is determined by the lowest rating of any item, i.e. the “worst score counts”.

3.7.2 Step two – quality assessment of instruments

The assessment of the quality of each questionnaire was completed using the criteria proposed by Terwee et al (2007) (see Appendix 3). Of note, no criterion is provided for structural validity.  Instead, for exploratory factor analyses, a criteria was used that has been outlined by previous systematic reviews (e.g. Schellingerhout et al., 2012), and for confirmatory factor analyses, a criteria was devised by the author after consultation with two other trainee clinical psychologists familiar with systematic reviews of measurement properties (see Appendix 3).

3.7.3 Step three – Best Evidence Synthesis (BES)

A BES was completed to summarise the evidence of the measurement properties for each questionnaire.  The results of different studies were combined taking account of the number and methodological quality of the studies, the results of the measurement properties that were evaluated, as well as the consistency of results across studies. Each questionnaire was given an overall rating using a criteria similar to that proposed by the Cochrane Back Review Group (see Furlan et al., 2009; van Tulder et al., 2003). The criteria was adapted from Schellingerhout et al (2012) and has been used by a recent systematic review (Heinl et al., 2016).

3.8 Measurement properties

The terminology and definitions of measurement properties used in this systematic review are taken from Mokkink et al (2010b).  The measurement properties are divided into 3 domains: reliability, validity and responsiveness. Reliability consists of internal consistency, reliability and measurement error. Validity contains content validity (including face validity), construct validity (further subdivided into structural validity, hypotheses testing, and cross-cultural validity) and criterion validity. The term responsiveness is used for both the domain and measurement property.

3.8.1 Measurement properties in this study

In this systematic review, only English versions of questionnaires were included; therefore cross-cultural validity was not assessed. Furthermore, since there is no ‘gold standard’ measure of self-criticism, criterion validity was not assessed. Of the included studies, no information was provided for responsiveness and measurement error (called ‘agreement’ in Terwee et al (2007) criteria). Focusing on the COSMIN interpretability box, information was only provided about how missing items were handled, and scores (i.e. means and standard deviations), meaning that the Terwee et al (2007) properties ‘floor and ceiling effects’ and ‘interpretability’ were not completed. Apart from those mentioned above, all other properties were assessed as part of steps 1 and 2 of the quality assessment.

4. Results

4.1 Selection of studies

The PRISMA flowchart is displayed in Figure 1. The database search resulted in a total of 4414 papers.  The grey literature search resulted in an additional 11 papers.  At this stage, unpublished version of a questionnaire of self-criticism (the Self-Critical Rumination Scale) was found and through contact with the author the (very recently) published paper was included for screening, therefore the total found through other sources was 12.

Removing duplicates left 2693 papers that were screened.  After screening these papers titles and abstracts, 2557 papers were excluded.The full text of 136 papers were reviewed and 125 of these were excluded.Of the 11 included papers, both reference checking and citation tracking resulted in the addition of 1 paper.

One additional paper (the Temperament & Personality Questionnaire development paper) was found through manual searching, from a study that was screened at the full text stage.  Although the study did not meet the inclusion criteria, through an internet search and contact with the author, the questionnaire’s original development paper was found and included.

 

 

4.1.1 Figure 1 PRISMA Flow Chart

Consort-Logo-Graphic-30-12-071

Additional records identified through other sources
(n = 12)

Records identified through database searching
(n = 4414)

Identification

Records after duplicates removed
(n = 2693)

Screening

Records excluded
(n = 2557)

Records screened
(n = 2693)

Full-text articles excluded, with reasons
(n = 125)

  • 1 full text not in English
  • 106 questionnaire doesn’t measure self-criticism
  • 13 not validation study
  • 5 not English language version of questionnaire

Full-text articles assessed for eligibility
(n = 136)

Additional studies

1 reference checking

1 citation tracking

1 manual search

Eligibility

Studies included in qualitative synthesis
(n = 14)

Included

4.2 Questionnaires found in search

This systematic review identified five questionnaires solely measuring self-criticism and five subscales measuring self-criticism. The questionnaires were grouped into the following categories: self-criticism as a trait, self-criticism in response to difficult situations, self-criticism as a mood regulation strategy and measures of repetitive self-criticism.

The questionnaire characteristics, including a description of the focus of the questionnaire, a description of the included items, probe statements and example items, and response options, are displayed in Appendix 1.  The characteristics of the included studies are displayed in Appendix 2.  As stated earlier, the quality criteria for the measurement properties assessed are displayed in Appendix 3. Appendix 4 displays the ratings for the methodological quality and measurement properties for internal consistency, reliability, content validity and structural validity.  Appendix 5 displays a separate table for construct validity (measured through hypothesis testing).  In this Appendix table, correlation coefficients and between group comparisons are presented.  Only correlations were extracted for constructs that were deemed to be the most relevant for self-criticism research.  These were self-criticism using a different questionnaire, self-esteem, self-compassion, mental health (for example, depression and general measures of anxiety), perfectionism, shame and rumination.

In the next section, the results per instrument are described. In Table 1 the results for each questionnaire are summarised into a Best Evidence Synthesis (BES). The BES summarises the evidence for each questionnaire taking account of the number and methodological quality of the studies (using COSMIN), the results of the measurement properties that were assessed within each study (see Appendix 3 for criteria), and the consistency of results across different studies. The BES resulted in each questionnaire being given an overall rating determined by predefined criteria that took account of both the methodological quality rating and the measurement property rating.

Table 7 Best Evidence Synthesis (BES)

Type of questionnaire Questionnaire Internal consistency Reliability Content validity Structural validity Hypothesis testing
Trait Self-Critical Cognition Scale + ? (limited) Weak + Weak
Trait Levels of Self-Criticism Scale + Not studied Weak ? (limited) ? (limited)
Trait Attitudes Towards Self Scale Not studied Weak Weak
Trait Attitudes Towards Self Scale-Revised Weak Weak + Weak
Trait Temperament & Personality Questionnaire ? (limited) Weak Weak + Not studied
Difficult situations Forms of Self-Criticising/Attaching and Self-Reassuring Scale ++ Not studied Weak ++ Conflicting findings
Difficult situations Self-Compassion Scale Conflicting findings Weak Weak Conflicting findings ++
Mood regulation Inventory of Cognitive Affect Regulation Strategies Conflicting findings Weak Weak Conflicting findings Conflicting findings
Repetitive self-criticism Habit Index of Negative Thinking Weak Weak Weak Not studied ++
Repetitive self-criticism Self-Critical Rumination Scale + ? (limited) +++ ++ +
Notes:

Overall rating (i) Level of evidence (ii) Criteria (iii)
+++ ; ? (strong) ; —

 

Strong Consistent findings in multiple studies of good methodological quality OR in one study of excellent methodological quality);
++ ; ? (moderate) ; – – Moderate Consistent findings in multiple studies of fair methodological quality OR in one study of good methodological quality
+ ; ? (limited) ; – Limited One study of fair methodological quality
Conflicting findings Conflicting Conflicting findings across studies
Weak Unknown Only studies of poor methodological quality
+ positive rating; ? indeterminate rating; – negative rating;

(i) Direction of rating (positive, indeterminate or negative) was based on the measurement property ratings (see Appendix 3);

(ii) Level of evidence was based on the methodological quality of studies;

(iii) Criteria was adapted from Schellingerhout et al (2012) and Heinl et al (2016).

4.3 Self-criticism as a trait

 4.3.1 Self-Critical Cognition Scale (SCCS)

Reliability

The development paper assessed internal consistency and test-retest reliability using separate samples. For both, the methodological quality of the study was rated as fair as it was not explained how missing items were handled.  In terms of the measurement properties, it received a positive rating for internal consistency.

Although it had a high test-retest correlation, it was given an indeterminate rating for test-retest reliability because it did not report an intraclass correlation (ICC).  Further issues around test-retest reliability were related to the lack of details about the administration of the questionnaire at time 1 and time 2, including whether the testing conditions were similar, or whether participants were stable over the specified time period.

Validity

The methodological quality of the development paper for content validity was rated as poor and it was given an indeterminate rating for this measurement property.  The target population was not stated and therefore there was no involvement of them in the item development or selection.

The methodological quality for structural validity was rated as fair and it was given a positive rating for this measurement property.  For hypothesis testing the methodological quality was rated as poor because there was a poor description of the comparator instruments used in the study.  It was given an indeterminate rating for this measurement property; no specific hypotheses were formulated and although for the majority of variables it was possible to deduce what was expected (for example, the relationship between self-criticism and self-esteem and depression), this was unclear for other variables (for example, shyness or social desirability).

Best Evidence Synthesis (BES)
  • The BES resulted in:
    • Limited positive evidence for internal consistency and structural validity;
    • Limited indeterminate evidence for reliability;
    • Unknown evidence for content validity and hypothesis testing due to the poor methodological quality.

4.3.2 Levels of Self-Criticism Scale (LSCS)

Reliability

The psychometric properties of the LSCS were assessed in the development paper, consisting of two studies.  The first study assessed internal consistency; the methodological quality was rated as fair due to lack of information about how missing items were handled, with a positive rating for this psychometric property.

Validity

For content validity, the methodological quality was rated as poor and this measurement property was given an indeterminate rating as there was no description of the target population and no involvement in the item development.  The methodological quality for structural validity was rated as fair, but it was given an indeterminate measurement property rating as the variance explained by the final factors was not mentioned.

The methodological quality for construct validity was rated as fair and it was given an indeterminate rating for this measurement property as only vague hypotheses were formulated.  For example, one might expect the two subscales to relate differently to two forms of perfectionism (‘self’ versus ‘other’), however, no details were given about the direction of the expected relationships.

Best Evidence Synthesis (BES)
  • The BES resulted in:
    • Limited positive evidence for internal consistency;
    • Limited indeterminate evidence for structural validity and hypothesis testing;
    • Unknown evidence for content validity due to the poor methodological quality;
    • Reliability was not studied.

4.3.3 Attitudes Towards Self Scale (ATSS)

Reliability

The methodological quality of the study for internal consistency was rated as fair. However, the measurement property was given a negative rating due to Cronbach alpha of the self-criticism subscale (less than 0.70).

Validity

The methodological quality for content validity was rated as poor and it was given an indeterminate rating for the measurement property; no clear description of the target population was given or involved with item development. Structural validity was rated as fair for the methodological quality but was given a negative rating for the measurement property as the factors only explained 40% of the variance. For hypothesis testing, the methodological quality was rated as poor and it was given an indeterminate rating for the measurement property.  In the study, no specific hypotheses were made a priori and it was unclear what was expected.

Best Evidence Synthesis (BES)
  • The BES resulted in:
    • Limited negative evidence for internal consistency and structural validity;
    • Unknown evidence for content validity and hypothesis testing due to the poor methodological quality;
    • Reliability was not studied.

 

4.3.4 Attitudes Towards Self Scale-Revised (ATSR)

Reliability

The psychometric properties of the ATTSR were assessed in one study with multiple samples. As with the original version, internal consistency was rated as fair for methodological quality and negative for the measurement property (the Cronbach alpha for the self-criticism subscale was 0.65).

For reliability, the test-retest correlation was low. The methodological quality was rated as poor as COSMIN states that two measurements (for time 1 and time 2) should be included in the study’s results. This measurement property was given an indeterminate rating as it assessed reliability using a statistical test other than that recommended by COSMIN (ICCs not specified).

Validity

For content validity, as in the original version, the ATSR was given a poor rating for methodological quality and an indeterminate rating for measurement property. Structural validity was assessed using a confirmatory factor analysis; the methodological quality was rated as fair and it was given a positive rating for this measurement property.

The methodological quality for hypothesis testing was rated as poor and it was given an indeterminate rating for this measurement property; no specific hypotheses were formulated and it was not possible to deduce what was expected. There was also a poor description of comparator instruments used.

Best Evidence Synthesis (BES)
  • The BES resulted in:
    • Limited positive evidence for structural validity;
    • Limited negative evidence for internal consistency;
    • Unknown evidence for reliability, content validity and hypothesis testing due to the poor methodological quality.

4.3.5 Temperament & Personality Questionnaire (TPQ)

Reliability

The psychometric properties of the TPQ were assessed in its development paper using two community samples. The methodological quality for internal consistency was rated as fair.  The measurement property was given an indeterminate rating because of the small sample size.  Furthermore, not all the subscales Cronbach alphas were greater than 0.70, and because separate values were not presented for each subscale, it is unclear what the Cronbach alpha was for the self-criticism subscale.

Reliability was rated as poor for methodological quality and an indeterminate rating was given for the measurement property.  There appeared to be a significant difference in depression scores between time 1 and time 2, suggesting that participants were not stable between the time interval.  Furthermore, the time interval (ranging from 5 – 150 days) was not considered appropriate for all participants.

Validity

The development paper was rated as poor for content validity, and an indeterminate rating was given due to no target population being specified or involved with item development. Structural validity was rated as fair for the methodological quality and positive for the measurement property.

Best Evidence Synthesis (BES)
  • The BES resulted in:
    • Limited positive evidence for structural validity;
    • Limited indeterminate evidence for internal consistency;
    • Unknown evidence for reliability and content validity due to the poor methodological quality;
    • Construct validity (hypothesis testing) was not studied.

4.4 Self-criticism in response to difficult situations

4.4.1 Forms of Self-Criticising/Attacking and Self-Reassuring Scale (FSCRS)

Reliability

The psychometric properties of the FSCRS were assessed in the original development paper (Gilbert et al., 2004), as well as in two additional studies that confirmed the factor structure of the questionnaire in a general population sample (Kupeli et al., 2013), and through secondary data analysis of data that had been collected by previous research studies (Baiao et al., 2015).  In all three studies, the methodological quality for internal consistency was rated as fair and they were given a positive rating for this measurement property.

Validity

The content validity was assessed in development paper; the methodological quality was rated as poor and it was given an indeterminate rating for the measurement property as there was no clear description of the target population and no involvement in the item development stage.

Structural validity was assessed in all three studies; the methodological quality was rated as fair with positive ratings for the measurement property.  For hypothesis testing, the three studies’ methodological quality was rated as fair. Of note, the development paper was one of the only studies to include another measure of self-criticism. Gilbert et al (2004) and Kupeli et al (2013) were given positive ratings for this measurement property.  Baiao et al (2015) investigated gender differences, however, because they did not give specific hypotheses about what was expected and it was unclear what was expected based in their results, an indeterminate rating was given.

Best Evidence Synthesis (BES)
  • The BES resulted in:
    • Moderate positive evidence for internal consistency and structural validity;
    • Conflicting findings for hypothesis testing;
    • Unknown evidence for content validity due to the poor methodological quality;
    • Reliability was not studied.

4.4.2 Self-Compassion Scale (SCS)

‘Self-judgement’ was considered to be a synonym of self-criticism and thus this subscale of the SCS met the inclusion criteria. The psychometric properties of the SCS were assessed in the development paper, divided into three studies.   There has also been further examination of its factor structure by Williams et al (2014) using three community samples.

Reliability

In the development paper, for internal consistency, the methodological quality was rated as fair and it was given a positive rating for the measurement property. For internal consistency Williams et al (2014) referred to the original 6 factors found in Neff (2003).  However, because they did not check unidimensionality themselves, the methodological quality was rated as fair and an indeterminate rating was given for the measurement property.

For reliability the test-retest correlation was high. However, the methodological quality of the development paper was rated as poor as COSMIN specifies that two measurements must be presented in the results.  The measurement property was given an indeterminate rating as ICCs were not presented.

Validity

In the development paper, content validity was assessed in undergraduates using focus groups.  The comprehensibility of the items were also checked by administering items to undergraduate participants.  However, because the target population was not clearly defined, and there was not enough information to assume that undergraduates were the target population, it was categorised as no target population involvement.  Thus, it was given a poor rating for the methodological quality and an indeterminate rating for this measurement property.

Structural validity was rated as fair for the methodological quality of the development paper but it was given an indeterminate rating for the measurement property because the amount of variance explained by the final factors was not presented. In Williams et al. (2014) for structural validity the methodological quality for two samples was rated as excellent, and a good rating was given to the third sample.  A negative rating was given for the measurement property has the original factor structure was not confirmed through confirmatory factor analyses, thus the self-judgement subscale was not replicated.

Hypothesis testing was completed in all three of the studies in the development paper.  The methodological quality was rated as fair and it was given a positive rating for the measurement property, although it is important to note that correlations were not presented for each subscale separately.

Best Evidence Synthesis (BES)
  • The BES resulted in:
    • Moderate positive evidence for hypothesis testing;
    • Conflicting evidence for internal consistency and structural validity;
    • Unknown evidence for reliability and content validity due to the poor methodological quality.

 

4.5 Self-criticism as a mood regulation strategy

4.5.1 Inventory of Cognitive Affect Regulation Strategies (ICARUS)

Reliability

The psychometric properties of the ICARUS were assessed in the development paper which consisted of three studies, and used two different populations (undergraduates and outpatients). Internal consistency was assessed in all three studies. In the first and second study the methodological quality was rated as good, but in the third study it was rated as poor due to a small sample size.  For all three studies the measurement property was given an indeterminate rating as the sample size did not equate to seven times the number of items in the questionnaire.

For reliability, the test-retest correlation was low.  The methodological quality was rated as poor and it was given an indeterminate rating for this measurement property.  These ratings were also due to the sample size used in the study (n = 28).

Validity

In relation to content validity, the target populations were clearly defined as individuals with a range of affect regulation styles including those who respond adaptively or poorly to small hassles or traumatic events, or who develop psychological disorders associated with affect dysregulation. However, as none of the target populations were used to assess whether all of the items were relevant for them, the methodological quality was rated as poor and it was given a negative rating.

For structural validity study one was rated as good for the methodological quality but was given an indeterminate rating for the psychometric property.  Study three also assessed structural validity; although it was given a positive rating for the psychometric property, the methodological quality was rated as poor because the sample size equated to less than five times the number of questionnaire items.

All of the studies in the development paper focused on hypothesis testing. Study two focused on hypothesis testing using both an experimental design and a between group comparison, and because of this, they were rated separately (labelled as 2A and 2B in Appendices 2, 4, & 5).Overall, there were mixed results for hypothesis testing. Two studies were rated as poor for the methodological quality with indeterminate ratings for the measurement property because no specific hypotheses were made and it was not possible to deduce what was expected (study 1 & 2B).  Study (2A) focused on the predictive validity of the ICARUS using a mood induction experiment. This study was rated as fair for methodological quality and an indeterminate rating was given for the measurement property.  The study design made the results difficult to interpret; although a mood induction paradigm was used, the level of distress after the mood manipulation was relatively mild and participants were only given a very short period to employ affect-regulation strategies. In study 3, the methodological quality was rated as fair and it was given a positive rating for this measurement property. However, it is important to note that no specific hypotheses were made about the self-criticism/self-blame subscale.

Best Evidence Synthesis (BES)
  • The BES resulted in:
    • Conflicting evidence for internal consistency, structural validity and hypothesis testing;
    • Unknown evidence for reliability and content validity due to the poor methodological quality.

4.6 Measures of repetitive self-criticism

4.6.1 Habit Index of Negative Thinking (HINT)

 

Reliability

The HINT is a measure of negative self-thinking, which is considered to be a synonym of self-criticism, and thus met the inclusion criteria. The psychometric properties of the HINT were explicitly assessed in four studies within the development paper.  The internal consistency was also assessed in one additional study (Verplanken, 2006).

Although the Cronbach alphas for the HINT were consistently high, the methodological quality of the studies were rated as poor as factor analysis had not been used to confirm unidimensionality.  This led to an indeterminate rating for this measurement property.

Despite the high test-retest reliability correlation,the methodological quality for test retest-reliability was rated as poor and an indeterminate rating was given for the measurement property. These ratings were given because ICCs were not used, and the results highlighted that 45% of participants had experienced at least one life event, suggesting that participants’ level of negative self-thinking may not have been stable during the time period.

Validity

The methodological quality of the study for content validity was rated as poor and a negative rating was given for this measurement property.  These ratings were given because although the target population was defined as a “non-clinical population” (Verplanken et al., 2007, P. 527), the items of the HINT were adapted from the Self-Report Habit Index (Verplanken & Orbell, 2003) and there was no target population involvement in adapting the items.

Hypothesis testing was assessed in four studies; all of which were given a fair rating for methodological quality due to no information regarding how missing items were handled. A positive rating was given for this measurement property as specific hypotheses were outlined and the results were in line with these.  Some of these studies specifically focused on the discriminant validity of the HINT, for example, whether negative self-talk differs from general negative thoughts.

Best Evidence Synthesis (BES)
  • The BES resulted in:
    • Moderate positive evidence for hypothesis testing;
    • Unknown evidence for internal consistency, reliability and content validity due to the poor methodological quality;
    • Structural validity was not studied.

4.6.2 Self-Critical Rumination Scale (SCRS)

Reliability

The SCRS is the most recently developed questionnaire of self-criticism. The psychometric properties were assessed in its development paper which consisted of four separate studies.

For internal consistency, the methodological quality was rated as fair and a positive rating was given for this measurement property.  The methodological quality for test-retest reliability was rated as fair.  Although the test-retest correlation was high, it was given an indeterminate rating for the measurement property because test-retest reliability was assessed using a statistical test other than what COSMIN recommends (ICCs were not used). Also, because the questionnaire was completed through an online survey, it was unclear whether the test conditions were similar for both measurements.

Validity

In study one, content validity was assessed using both undergraduates and out-patients at a mental health clinic. As enough information was provided to assume that these were the target populations, the methodological quality was rated as excellent and it was given a positive rating for this measurement property.

Structural validity was assessed using both an exploratory and confirmatory factor analysis in separate studies.  For both, the methodological quality was rated as fair and it was given a positive measurement property rating.

The construct validity was assessed through hypothesis testing using a large number of self-report questionnaires, including those that measured constructs particularly pertinent to the SCRS such rumination.  The methodological quality was rated as fair and it was given a positive rating for this measurement property; specific hypotheses were formulated and the majority of the results were in line with hypotheses.

Best Evidence Synthesis (BES)
  • The BES resulted in:
    • Strong positive evidence for content validity;
    • Moderate positive evidence for structural validity;
    • Limited positive evidence for internal consistency and hypothesis testing;
    • Limited indeterminate evidence for test-retest reliability.

 

 

5. Discussion

The aim of this systematic review was to identify and evaluate the measurement properties of self-report measures of self-criticism. It took account of the methodological quality of the studies, and a Best Evidence Synthesis (BES) was completed. This review found five questionnaires that solely focused on self-criticism, and five that had a subscale measuring self-criticism. These ten questionnaires were further subdivided into categories based on the aim of their questionnaire.

The main theme that emerged from this systematic review was that the majority of studies were either rated as having poor methodological quality, or were given indeterminate or negative ratings for the measurement properties they studied. As well as this, two key issues emerged.  Firstly, self-criticism was conceptualised differently by authors, leading to questionnaires with different content and structure. Furthermore, the way that self-criticism was defined was, at times, very broad or unclear. Thinking specifically about self-report measures, not having a clear or precise definition of self-criticism could impact on the item development and consequently its measurement properties, particularly those associated with the questionnaire structure, such as internal consistency and structural validity.  It could also lead to a poor theoretical basis about the relationship self-criticism has with other constructs, affecting the quality of hypothesis testing.

Related to this, the second issue was the disparity between what a questionnaire aimed to measure, and the actual items used.   As the focus of this systematic review was on questionnaires that “aimed to” measure self-criticism, the individual items were not formally evaluated. Nevertheless, on inspection, some items could be construed as measuring different affect or reactions to failure, high personal standards, and other distinct but overlapping constructs such as perfectionism, shame or self-esteem. This issue is discussed further below when discussing evidence for the different scales and in relation to face validity.

5.1 Self-criticism scales and subscales

5.1.1 Self-criticism as a trait

Two questionnaires and one subscale defined self-criticism as a dispositional tendency or broad personality construct. In terms of the BES, both the Self-Critical Cognition Scale (SCCS) and the Levels of Self-Criticism Scale (LSCS) had limited positive evidence for internal consistency and the SCCS had limited positive evidence for structural validity.  However, the other measurement properties consisted of a mixture of limited indeterminate or weak evidence due to the poor methodological quality. There also appeared to be issues related to the questionnaire items; the LSCS did not mention the term self-criticism and the SCCS included broader items about the inability to keep a balanced perspective, and the exaggeration of negative aspects of oneself.

Authors of the Temperament and Personality Questionnaire (TPQ) defined self-criticism as a personality construct, specifically viewing it as predisposing individuals to depression. Apart from limited positive evidence for structural validity of their self-criticism subscale from the BES, the TPQ only had limited indeterminate or weak evidence. Furthermore, although the subscale items of the 109-item version appeared to have a more specific focus on self-criticism or being tough on oneself, the TPQ research team have cautioned the use of this version due to confusion over scoring (R. Graham, personal communication, January 15, 2016). It is also unclear which items are part of the self-criticism subscale within the other versions of the questionnaire.

The Attitudes Towards Self Scale (ATSS) and the ATSS Revised (ATSSR) conceptualised self-criticism as one of three potential self-regulatory vulnerabilities to depression. Of note, however, the actual items appeared to focus on reactions to failure, rather than specifically self-criticism. The BES highlighted that there was only limited positive evidence for the ATSSR’s structural validity, and other than this, there was a mixture of limited negative or weak evidence.

Looking at these results as a whole, it would suggest that there is limited positive evidence for questionnaires that view self-criticism as a trait.  It could also be argued that there are issues with conceptualising self-criticism as a personality or self-regulatory dimension as it leads to a very broad definition and studies often lack detail about how to characterise this further. Furthermore, some questionnaires that view self-criticism as a personality construct (such as the LSCS), cite the research about Blatt’s depression vulnerability theory, or the Depressive Experiences Questionnaire (DEQ) (Blatt, D’Afflitti & Quinlan, 1976). This could lead to further confusion about the conceptualisation of self-criticism because the DEQ aims to measure ‘introjective depression’ rather than the construct self-criticism.  Thus, the ‘self-criticism’ factor of the DEQ contains items that reflect a range of different constructs such as guilt, emptiness and hopelessness, as well as feeling unsatisfied, unable to assume responsibility and being threatened by change. A questionnaire that is influenced by the DEQ may therefore develop items that go beyond the construct of self-criticism, and may in turn affect the validity and reliability of the measure.

5.1.2 Self-criticism in response to difficult situations

This systematic review identified one scale and one subscale that focused on self-criticism when things go wrong for someone, or in difficult times.  Firstly, the Forms of Self-Criticizing/Attacking Reassuring Scale (FSCRS) included items about self-criticism and other negative feelings about oneself in relation to failure such as disappointment, inadequacy and disgust. The psychometric properties were assessed in multiple studies; the BES resulted in moderate positive evidence for internal consistency and structural validity.

In terms of hypothesis testing, different studies received different ratings for this measurement property, resulting in ‘conflicting findings’ in the BES.  Two studies received positive ratings as the results were in line with hypotheses made a priori. Of note, the development paper was one of the only studies to include another measure of self-criticism, thus allowing a comparison between different measures. Baiao et al (2015) received an indeterminate  rating as it did not state hypotheses about expected gender differences, and based on their results (significant gender differences in only the non-clinical population), it was unclear what was expected.

 

The Self-Compassion Scale (SCS) conceptualised self-judgement (considered a synonym of self-criticism) as a negative component of self-compassion. The items focus being disapproving and intolerant about an individual’s flaws and other aspects of themselves they don’t like. The SCS had moderate positive evidence for hypothesis testing in the BES; the development paper included multiple hypotheses formulated a priori and the results were in accordance with these. It received a positive rating for internal consistency in development paper, however, the BES resulted in conflicting findings due to the indeterminate rating given to Williams et al (2014) for this measurement property. Similarly, the SCS’s structural validity was summarised as having conflicting findings. The development paper received an indeterminate rating for this measurement property as the amount of variance explained by factors was not recorded.  Williams et al (2014), whose methodological quality was rated as good and excellent for different samples, completed a series of confirmatory factor analyses which did not confirm Neff’s original six factor structure, including the self-judgement subscale, resulting in a negative rating for this measurement property.  This suggests that there are potential issues with the original structure of the SCS proposed by Neff. Finally, the SCS received a weak rating for content validity in the BES. Although the items were piloted in undergraduates, the development paper also used the questionnaire with Buddhist individuals, meaning that it was unclear what the target population was.

5.1.3 Self-criticism as a mood regulation strategy

The Inventory of Cognitive Affective Regulation Strategies (ICARUS) defined self-criticism/self-blame as one of many cognitive strategies that an individual might use when experiencing negative affect. Items focus on self-criticism but also include broader items such as concentrating on, or repetitively thinking about negative emotions. The BES resulted in conflicting findings for internal consistency, structural validity and hypothesis testing, and weak evidence for reliability and content validity due to the poor methodological quality of the studies. One consistent theme with the ICARUS was because it has a total of 59 items, it fell down on COSMIN items that were related to sample sizes, which were often too small in relation to the total number of items. Future research would therefore need to use a relatively large sample size to secure better methodological ratings for this measure.

5.1.4 Measures of repetitive self-criticism

Two measures of repetitive self-criticism were identified; the Self-Critical Rumination Scale (SCRS) and the Habitual Index of Negative Thinking (HINT). The SCRS focused on both the process of self-criticism in terms of frequency and repetitiveness and its content, including feeling ashamed of oneself. Its psychometric properties were evaluated in a very comprehensive development paper.  The BES resulted in moderate positive evidence for structural validity and limited positive ratings for internal consistency and hypothesis testing. Although the test-retest reliability was high, it received an indeterminate rating for this measurement property as ICCs were not used. The SCRS was the only questionnaire to receive a positive rating for content validity; because the items were piloted in both a non-clinical and clinical population there was enough information to assume that these were its target populations.

The HINT was the only measure that focused solely on the process of negative self-thinking (considered to be a synonym of self-criticism) as a habit, as opposed to focusing on the content.  It measured different features of the concept of a habit, such a frequency, lack of conscious intent and lack of awareness of initiation. The BES resulted in weak evidence for content validity, internal consistency and reliability due to the poor methodological quality of the studies. Methodological issues included no target population involvement in item development stage for content validity, and the lack of stability of participants between measurements for test-retest reliability. Furthermore, although the Cronbach alphas were consistently high for the HINT, no factor analyses were performed to confirm unidimensionality of the scale. Although the BES resulted in moderate positive evidence for hypothesis testing, this is difficult to interpret in the context of the issues described above.

 

5.2 Assessing the methodological quality of included studies

This systematic review used COSMIN to assess the methodological quality of the included studies. COSMIN uses a “worst score counts” method whereby an overall score is determined by the lowest rating of any item.  A number of themes emerged in regards common areas where studies were marked down on.

5.2.1 Issues with content validity

Firstly, apart from the SCRS, all measures were given a poor methodological quality rating for content validity.  The COSMIN item where all studies fell down on was question two: “was there an assessment of whether all items are relevant for the study population?” In the majority of studies the items were developed by the authors. Although this is important as they would be considered as ‘experts’ in their field, according to COSMIN, it is also crucial for studies to define their target population and use individuals from this population to assess the included items. Furthermore, inspection of the study characteristics highlighted that the majority of studies used an undergraduate population, and it cannot be assumed that this was the intended target population of each questionnaire. This issue is particularly important for self-criticism, which researchers wish to measure in a wide range of non-clinical and clinical populations. Thus, defining the target population and making sure the items are relevant for them prior to using the questionnaire is crucial for the accurate measurement of self-criticism.

5.2.2 Issues with reliability

Secondly, for test-retest reliability only one study (Parker et al., 2006) explicitly stated that Intraclass Correlation Coefficients (ICCs) were calculated. COSMIN state that ICCs are the preferred statistical method for test-retest reliability with continuous scores as Pearson’s and Spearman’s correlation coefficients do not take account of systematic error (Mokkink et al., 2012). Because ICCs were not used by the majority of studies, the test-retest reliability correlation has been mentioned for each scale, i.e. whether it was high or low. This seemed appropriate because, although scales received the same COSMIN rating, some had test-retest reliability correlations that were less than 0.70, which is widely accepted as being an unacceptable test-retest reliability value (Test-Retest Coefficient, 2016).

In the BES there was weak evidence for the test-retest reliability for five questionnaires (the HINT, TPQ, ATSSR, SCS and the ICARUS).  Methodological issues with reliability included the use of inappropriate time intervals, not presenting two measurements (i.e. means and SDs) in the study results, and not ensuring the stability of participants between time points.  Because of the consistent weak ratings for reliability, it is recommended that this should be an area for high quality future research.

5.2.3 A COSMIN ‘fair’ rating

Finally, a large number of studies were given a fair rather than a good rating across measurement properties due to a lack of information about how missing items were handled. Whilst it is assumed that all researchers carefully consider how to handle missing items, not explicitly including this information does not allow for a full interpretation of the study’s findings.  For example, if there were large number of missing items, the decision to include or exclude these from the analysis may impact on the final results.

5.2.4 Assessing face validity?

A possible limitation of COSMIN is that it does not have a criteria to evaluate the face validity of each questionnaire, defined as the degree to which items of a questionnaire look as though they are an adequate reflection of the construct to be measured (Mokkink et al., 2010B). In the COSMIN manual it states that because face validity involves subjective judgement no criteria has been developed (Mokkink et al., 2012). However, without criteria for face validity, it is possible that a questionnaire could be given positive ratings for both the methodological quality of a study and the measurement properties but the items may not actually measure self-criticism. Therefore researchers and clinicians selecting a measure are urged to check that the scale probe question, items and response ratings appear assessing the construct of interest to them, rather than focusing purely on the findings from the BES. It would be helpful for future research to focus on the development of a set of criteria to formally assess face validity. This may be particularly pertinent for research areas such as self-criticism where there is no universally agreed definition of this construct.

5.3 Recommendations

Tentative recommendations are given based on the current level of evidence (future high quality studies may change these recommendations).  It is also important to emphasise that, due to the different conceptualisations of self-criticism, the questionnaire of choice will ultimately depend on the particular research approach or question.

Since the SCRS had consistent positive ratings, this systematic review would recommend its use in future research if the focus is on frequent or repetitive self-critical thinking. In regards to the FSCRS, because of its moderate positive evidence for internal consistency and structural validity, this systematic review would also recommend this measure for researchers or clinicians wishing to assess self-criticism in response to things going wrong, particularly if they also wanted to assess self-hatred separately and / or self-reassurance.  It would be important for future studies to focus on its test-retest reliability as this has not yet been assessed.

Due to the limited positive evidence for questionnaires that define self-criticism as a broad personality or self-regulatory dimension, it is recommended that future research either conduct high quality studies focused on their measurement properties or develop and evaluate alternative measures. Of note, because of the lack of positive evidence for the ATSS and ATSSR it is recommended that these subscales are not used to measure self-criticism in future research. In regards to the other subscales of self-criticism, because of the limited positive evidence, conflicting or weak evidence for the TPQ, SCS and the ICARUS, this systematic review cannot make strong recommendations about their use to measure self-criticism.

The HINT has it’s a unique focus on solely the process of habitual negative self-thinking, so researchers and clinicians may be keen to use this scale. However, the methodological quality of the studies was poor, so further research is required to assess the psychometric properties in high quality studies.

 

In terms of more general recommendations, it is suggested that future studies assessing construct validity include more than one measure of self-criticism to allow for better comparison between measures. Furthermore, none of the included studies assessed every measurement property.  Of note, responsiveness, defined as the ability of a questionnaire to detect clinically important changes over time (see both Terwee et al., 2007 & Mokkink et al., 2010b), was not assessed in any study.  This would be particularly important to explore in future studies, as self-criticism is being targeted through specific interventions, and therefore these questionnaires will potentially be used as outcome measures. Lastly, future research could consider using COSMIN to aid the development of a new measures of self-criticism.

5.4 Limitations

This systematic review has a number of limitations. Firstly, only including studies that focused on the English version of self-report measures may have resulted in selection bias.  However, the inclusion of translated versions could have resulted in inconsistent findings regarding the measurement properties of the same questionnaire; because of this, it has been suggested that separate systematic reviews are conducted for translated versions of measures (Schellingerhout et al., 2010).

Secondly, this systematic review only included studies that were specifically focusing on the evaluation of psychometric properties of self-report questionnaires.  It could therefore have excluded some studies with an experimental design that evaluated properties as part of this, for example, calculating the Cronbach alpha for the study population.

Finally, this systematic review only included questionnaires that specifically aimed to measure self-criticism.  As highlighted previously, some studies have used measures that were not originally designed to measure self-criticism such as the Dysfunctional Assumptions Scale (DAS) (Weissman & Beck, 1978) and the DEQ (Blatt, D’Afflitti & Quinlan, 1976).  However, it is hoped that by not including these in this systematic review it will act as a strong caution to future researchers, as only scales or subscales specifically designed to measure a particular construct will lead to truly valid and reliable results.

5.5 Conclusions

Valid and reliable measures of self-criticism are need by both researchers and clinicians. This systematic review evaluated the measurement properties of scales and subscales measuring self-criticism, as well as assessing the methodological quality of included studies. Five scales and five subscales were found across 14 studies. These scales were designed to measure four main different types of self-critical thinking: trait self-criticism, repetitive self-criticism, self-criticism in response to difficult situations and self-criticism as a as a mood regulation strategy.  Across all questionnaires, there were issues with content validity, specifically around defining and involving target populations with item development. Furthermore, although not formally evaluated, there appeared to be issues with the final items included in the questionnaires; the majority appeared to measure ideas and constructs beyond the construct of self-criticism.  This therefore highlighted the need for a standard criterion to be developed measuring face validity. Finally, although tentative recommendations were made about the use of the SCRS and the FSCRS on the basis of existing evidence, further high quality research is needed into these and some of the other scales.    Due to differences between the precise focus of measures, such as self-critical rumination or self-criticism at times of difficulty, the final decision about which questionnaire to use will ultimately depend on the goals of the researcher or clinician.

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Appendices contents page

Appendix 1. Table 2 – Questionnaire Characteristics

Appendix 2. Table 3 – Study characteristics

Appendix 3. Table 4 – Quality criteria for measurement properties assessed

Appendix 4. Table 5 – Ratings for methodological quality and measurement properties

Appendix 5. Table 6 – Ratings for construct validity

Appendix 1. Table 2 Questionnaire Characteristics

Questionnaire Type of questionnaire Original reference Questionnaire designed to measure Description of items Probe statements & example items Items for scales or self-criticism subscales Response options (Likert scales)
Self-Critical Cognition Scale Trait Ishiyama & Munsun (1993) To assess the “dispositional tendency” to process information about the self in a self-critical way. (P. 148). It has two subscales: ‘Negative-self processing’ & ‘Failure in positive self-processing’. Items focus on self-criticism, making negative social comparisons, an inability to keep a balanced perspective about oneself & exaggeration of negative aspects of oneself Probe statement: unclear. Negative self-processing: “I tend to blow my weaknesses, limitations and mistakes out of proportion in my thinking”; Failure in positive self-processing: “I’m good at looking at myself critically while still remaining positive toward myself” (P. 150) 13 6-point (agree-disagree scale)
Levels of Self-Criticism Scale Trait Thompson & Zuroff (2004) Self-criticism is conceptualised as a broad personality construct consisting of two developmental levels (Comparative Self-Criticism (CSC) and Internalised Self-Criticism (ISC)). CSC is defined as a negative view of oneself compared with other people. ISC is defined as a negative view of oneself compared with internalised personal standards. No mention of self-criticism. CSC items focus on social anxiety, concerns & dilemmas. ISC items focus on affect & reactions to failure, high personal standards & experience of shame Probe statement: unclear. CSC: “I don’t spend much time worrying about what other people will think of me (Reversed)”; ISC: “When I don’t succeed, I find myself wondering how worthwhile I am” (P. 424) 22 7-point (1 =not at all; 7= very well)
Attitudes Towards Self Scale Trait (subscale) Carver & Ganellen (1983) The ATSS measures three self-regulatory vulnerabilities to depression (high-standards, overgeneralisation and self-criticism).  Self-criticism is defined as making harsh judgements of oneself for failing to attain a standard. No mention of self-criticism. Items focus on affect & reactions to failure & high personal standards Probe statement: unclear. “When my behaviour doesn’t live up to my standards, I feel I have let myself or someone else down” (P. 333) 4 5-point (1= extremely untrue, 5= extremely true)
Attitudes Towards Self Scale-Revised Trait (subscale) Carver et al (1988) As above – the ATSSR was developed to produce “cleaner” subscales. (P. 352) No mention of self-criticism. Items focus on affect & reactions to failure Probe statement: unclear. “I get angry with myself if my efforts don’t lead  to the results I wanted” (P. 353) 3 5-point (‘I agree very strongly’ to ‘I disagree very strongly’, middle option ‘neither agree nor disagree’)
Temperament & Personality Questionnaire Trait (subscale) Parker et al (2006) The TPQ measures personality traits or constructs thought to predispose individuals to depression. Self-criticism is defined as the tendency to be very tough on oneself. Items focus on self-criticism, being tough/hard on oneself, high personal standards & a sense of satisfaction with oneself Probe statement: “Please tick the option that best describes the way you usually or generally feel or behave (over the years and not just recently”. Item: “I find it hard to measure up to my own standards” (available online) Multiple versions of TPQ (81, 89 & 109-item versions). 4 or 8 in 109-item version 4-point (3= very true; 2= moderately true, 1= slightly true, 0= not true at all)
Forms of Self-Criticising/Attacking and Self-Reassuring Scale In response to difficult situations Gilbert et al (2004) To assess forms of self-attacking when things go wrong for people. Separated into two forms: ‘Inadequate self’ focuses on attending to failures and inadequacies, and ‘Hated self’ focuses on more aggressive/disgust based self-attacking. Also, measures ‘self-reassurance’, defined as the ability to be reassuring to oneself when things go wrong. Items focus on self-criticism, disliking oneself, not feeling good enough and other feelings about oneself associated with failure including disappointment, inadequacy, anger, frustration & disgust. There are also positively worded items about feeling good enough, loveable & acceptable Probe statement: “When things go wrong for me…” Items: Inadequate self: “I remember and dwell on my failings”; Hated self:“I call myself names”; Reassure self:“I am able to remind myself of positive things about myself” (P. 37) 22 (Kupeli et al (2013) developed 18-item version) 5-point (0= not at all like me, 4= extremely like me)
Self-Compassion Scale In response to difficult situations Neff (2003) The SCS assesses levels of self-compassion in terms of 3 main components (divided into 6 sub-scales): self-kindness VS self-judgement; common humanity VS isolation; mindfulness VS over-identification. Self-judgement is conceptualised as a negative component of self-compassion, and is defined as being disapproving or judging of one’s inadequacies and failures. Items focus on self-judgement; being disapproving, intolerant & impatient about flaws, inadequacies & aspects of one’s personality that you don’t like First probe statement: “How I typically act towards myself in difficult times” Item: “When I see aspects of myself that I don’t like, I get down on myself” (available online) 5 5-point (1= Almost never, 5= Always always)
Inventory of Cognitive Affect Regulation Strategies Mood regulation strategy Kamholz et al (2006) The ICARUS assesses the deliberate and conscious cognitive affect-regulation strategies people use to reduce distressing emotions.  Self-criticism/self-blame is defined as focusing on one’s own perceived weakness and inadequacy. Items focus on self-criticism, self-blame & thoughts about one’s shortcomings, faults & mistakes. Also broader items focused on concentrating on negative emotions or repetitive thinking in response to negative emotions First probe statement: “Indicate what you generally think about to make your mood better when you are sad…” Item: “I think about all my shortcomings, failings, faults and mistakes” (P. 231) 6 4-point (1= I don’t do this at all; 2= I do this a little bit; 3= I do this a medium amount; 4= I do this a lot)
Habit Index of Negative Thinking Repetitive self-criticism Verplanken et al (2007) A measure of the habit of negative self-thinking (adapted from the Self-Report Habit Index (Verplanken & Orbell, 2003). Focuses on the way a person thinks (as opposed to the content of thoughts). Items focus on aspects of negative self-thoughts including whether they are frequent, automatic, unintentional & difficult to disengage from. First probe statement: “Thinking negatively about myself is something…” Item: “I do frequently” (P. 541) 12 Verplanken (2006): 5-point (1= disagree completely, 5= agree completely). Verplanken et al (2007) used both 7-point & 5-point ( ‘strongly disagree’ to ‘strongly agree’)
Self-Critical Rumination Scale Repetitive self-criticism Smart, Peters & Baer (2015) To assess self-critical rumination. Self-criticism is conceptualised as a form of negative thinking that focuses on devaluing oneself. Items also focus on ruminative qualities of thinking: “frequent, prolonged, repetitive & difficult to control”. (P. 2). Items focus on frequency & repetitiveness of self-criticism. Items also explore the content of thoughts, for example, whether someone focuses on aspects of themselves that they are ashamed of First probe statement: unclear. “My attention is often focused on aspects of myself that I’m ashamed of” (P. 6) 10 4-point (1= not at all, 2=a little, 3= moderately, 4=very much)

Notes: CSC: Comparative self-criticism; HS: Hated self; ICS: Internalised self-criticism; IS: Inadequate self; RS: Reassured self.

Appendix 2. Table 3 Study Characteristics

Questionnaire Author(s) N Population Diagnoses Age – Mean (SD) Demographic information Means & SDs (scales or self-criticism subscales) Country Missing items
SCCS Ishiyama & Munsun (1993) Sample (1) 561 Undergraduates N/A 22.3 (6.1) Victoria University; 27.1 (9.0) McGill university Total sample – 210 males; 350 females;1 unidentified sex. Victoria University – 182 males; 272 females. McGill university 28 males; 78 females; 1 identified sex Total sample = 40.3 (11.2); males = 39.6 (10.1); females = 40.8 (11.8). Canada NR
SCCS Ishiyama & Munsun (1993) Sample (2) 142 Unclear N/A NR 83 males; 59 females  T1 = 39.1 (11.9). T2 = 38.3 (11.9) Unclear NR
LSCS Thompson & Zuroff (2004) Study (1) 282 Undergraduates N/A NR 144 females; 138 males N/A USA/Canada NR
LSCS Thompson & Zuroff (2004) Study (2) 144 Undergraduates N/A NR 75 females; 69 males NR USA/Canada NR
ATSS Carver & Ganellen (1983) Sample (1) 1083 Undergraduates N/A NR 594 males; 489 females N/A USA NR
ATSS Carver & Ganellen (1983) Sample (2) 502 Undergraduates N/A NR 260 males; 242 females See Appendix 5 – Construct validity USA NR
ATSSR Carver et al (1988) Study (1) 478 University students N/A NR NR N/A USA NR
ATSSR Carver et al (1988) Study (2 ) & (4 ) (data combined) Study 2 n = 170; Study 4 n = 219 (samples combined for analyses) University students N/A NR NR NR USA NR
ATSSR Carver et al (1988) Study (4) (subset of participants) 197 University students N/A NR NR NR USA NR
ATSSR Carver et al (1988) Study (5) (depression group) Depression group n = 5; Control group n = 11 Inpatients & hospital staff Depression NR NR NR USA NR
ATSSR Carver et al (1988) Study (5) (whole patient group) 70 Inpatients 24 Bipolar Disorder (12 in manic phase); 17 Schizophrenia; 7 SchizoAffective Disorder; 7 Atypical Psychosis; 5 Major Depression; 3 Dysthymic Disorder; 3 Adjustment Disorder; 2 Alcohol Dependence; 1 Schizophreniform Disorder; 1 Unspecified Nonpsychotic Mental Disorder 33.1 (9.43) NR NR USA NR
TPQ Parker et al (2006) Sample (1) 529 Community sample (recruited at GP surgery) N/A 35.5 (14.1) 54% females N/A Australia NR
TPQ Parker et al (2006) Sample (2) 52 Outpatients Depression 41.3 (NR) 51.9% females NR Australia NR
FSCRS Gilbert et al (2004) 246 Undergraduates N/A 27.7 (7.2) All females Total sample – IS = 16.75 (8.44); HS = 3.86 (4.58); RS = 19.81 (5.92) UK NR
FSCRS Kupeli et al (2013) Sample (1) 764 University students & community sample (recruited online) N/A 28.6 (10.6) Gender – 18.1% males (n = 138); 81.9% females (n = 626). Ethnicity – 76.2% White (n = 582). N/A UK NR
FSCRS Kupeli et al (2013) Sample (2) 806 As above N/A 28.3 (10.6) Gender – 17% males (n = 137); 83% females (n = 669). Ethnicity – 74.4% White (n = 600). N/A UK NR
FSCRS Kupeli et al (2013) Sample (3) 1224 (deduced by author) Community sample (recruited online) N/A NR NR See Appendix 5 – Construct validity UK NR
FSCRS Baião et al (2015) Non-clinical n = 887. Clinical n = 171 (after 4 excluded) Secondary analyses on data from 12 previous studies (7 non-clinical; 5 clinical groups) 100 (58.48%) Depression; 16 (9.36%) Personality Disorder; 13 (7.60%) Substance Abuse; 9 (5.26%) Anxiety; 3 (1.54%) Bipolar Disorder. (Missing data = 30) Non-clinical population = 24.13 (7.79). Clinical population = 44.22 (12.05) (missing data = 23 clinical participants) Non clinical population – 210 males; 676 females. Clinical population – 67 males; 91 females (missing data for 13 clinical participants) See Appendix 5 – Construct validity UK NR
SCS Neff (2003) Study (1) – content validity Focus group n = 68. Piloting of items n = 71 Undergraduates N/A Focus group= 21.7 (2.32). Piloting of items = 21. (2.03) Focus group – 30 males; 38 females. Piloting of items – 24 males; 47 females N/A USA N/A
SCS Neff (2003) Study (1) – main study 391 Undergraduates N/A 20.91 (2.27) Gender – 166 males; 22 females. Ethnicity – 58% White; 21% Asian; 11% Hispanic; 4% Black; 6% other Total sample = 3.14 (0.79); Males = 3.00 (0.81); Females = 3.24 (0.77) USA NR
SCS Neff (2003) Study (2) 232 Undergraduates N/A 21.31 (3.17) Gender – 87 males; 145 females. Ethnicity – 58% White; 22% Asian; 14% Hispanic; 3% Black; 3% other. NR USA NR
SCS Neff (2003) Study (3) Students n = 232; Buddhist n = 43 Community sample (recruited from Buddhist email list subscription) N/A Students = 21.31 (3.17); Buddhists = 47 (9.71) Students: Gender – 87 males; 145 females. Ethnicity – 58% White; 22% Asian; 14% Hispanic; 3% Black; 3% other. Buddhists: Gender – 16 males; 27 females. Ethnicity – 91% White; 5% Asian; 2% other. See Appendix 5 – Construct validity USA NR
SCS Williams et al (2014) Sample (1) 821 Community sample (recruited online) N/A 25.7 (9.8) Gender – 697 females (74.1%). Ethnicity – 800 (85.1%) White; 140 14.9%) Other 12.10 (4.40) UK EX
SCS Williams et al (2014) Sample (2) 211 Community sample (recruited online) N/A 46.51 (13.1) Gender – 153 females (65.1%). Ethnicity – 216 (91.9%) White; 19 (8.1%) Other 17.15 (4.29) UK EX
SCS Williams et al (2014) Sample (3) 390 Community sample (recruited through MBCT trial) Recurrent Depressive Disorder 50.16 (11.8) Gender – 325 females (76.6%). Ethnicity – 410 (96.7%) White; 4 (0.9%) Other; 10 (2.4%) Missing 11.81 (3.93) UK EX
ICARUS Kamholz et al (2006) Study (1) Pilot study 1 n = 193; Pilot study 2 & main sample used n = 398 (after 28 excluded) Undergraduates N/A 86.2% = 21 years and younger Gender – 59% females. Ethnicity – 44.8% Caucasian; 30.7% Hispanic; 12.1% African American; 7.1% Asian; 5.3% Other or mixed 2.38 (0.64) USA EX
ICARUS Kamholz et al (2006) Study (2A) 132 Undergraduates N/A 20.27 (3.24) Gender 62% females. Ethnicity – 46.8% Caucasian; 34.1% Hispanic; 10.3% African American; 8.7% Asian 1.49 (0.61) USA NR
ICARUS Kamholz et al (2006) Study (2B) 132 Undergraduates N/A As above As above As above USA NR
ICARUS Kamholz et al (2006) Study (3) 208 Outpatients 137 (66%) Substance-Use Disorder; 129 (62%) at least one Axis I psychiatric diagnosis; 93 (45%) two diagnoses; 62 (30%) three diagnoses. 91 (71%) mood disorder; 54 (42%) PTSD; 33 (26%) non-PTSD anxiety disorder 48; (37%) Psychotic Disorder  49 (7.98) Gender – n = 201, 97% males. Ethnicity – n = 140, 67.3% Caucasian; n = 54, 26% African-American; n = 2, 1% Hispanic, n = 4, 1.9% Native American; 8, 3.8% Other. 2.38 (0.75) USA NR
HINT Verplanken (2006) Study (2) 194 University students N/A NR 123 females;71 males 2.32 (1) Norway NR
HINT Verplanken et al (2007) Study (1) 157 University students N/A NR 95 females; 61 males (1 participant did not disclose) NR Norway NR
HINT Verplanken et al (2007) Study (4) 155 University students N/A NR 88 females; 66 males (1 participant did not disclose) 2.70 (1.05) Norway NR
HINT Verplanken et al (2007) Study (5) 125 University students N/A NR 79 females; 46 males 3.03 (1.36) USA NR
HINT Verplanken et al (2007) Study (8) T1: n = 1682. T2: n = 1102 Community sample (recruited via postal system) N/A 40.27 (8.23) T1: 939 females; 736 males (7 did not disclose). T2: 641 females; 461 males T1 = 2.72 (1.56). T2: NR Norway EX
SCRS Smart, Peters & Baer (2015) Study (1) Undergraduates n = 25; adult outpatient n = 13 Undergraduates & outpatients N/A NR NR N/A USA N/A
SCRS Smart, Peters & Baer (2015) Study (2) 420 (after 90 excluded) Undergraduates N/A 18.99 (1.44) Gender – 51.9% females. Ethnicity – 71.9% Caucasian. 2.17 (0.73) USA NR
SCRS Smart, Peters & Baer (2015) Study (3) 143 Undergraduates N/A 19.00 (1.46) Gender – 69.9% females. Ethnicity – 72.2% Caucasian. N/A USA NR
SCRS Smart, Peters & Baer (2015) Study (4) 70 Undergraduates N/A NR Gender – 89.9% female. Ethnicity – 91.3% Caucasian  T1 = 1.90 (SE = 0.08); T2 = 1.83 (SE = 0.08) USA NR

Notes: ATSS: Attitudes Towards Self Scale; ATSR: Attitudes Towards Self Scale-Revised; FSCRS: Forms of Self-Criticising/Attaching and Self-Reassuring Scale; HINT: Habit Index of Negative Thinking; HS: Hated self; ICARUS: Inventory of Cognitive Affect Regulation Strategies; IS: Inadequate self; LSCS: Levels of Self-Criticism Scale; N/A: Not applicable; NR: Not recorded; RS: Reassured self; SD: standard deviation; SCCS: Self-Critical Cognition Scale; SCRS: Self-Critical Rumination Scale; SCS: Self-Compassion Scale; TPQ: Temperament & Personality Questionnaire; T1: Time 1; T2: Time 2.

Appendix 3. Table 4 Quality criteria for measurement properties assessed

Property Definition Quality criteria based on Quality criteria
Internal consistency The extent to which items in a (sub) scale are intercorrelated, thus measuring the same construct Terwee et al (2007) + Factor analyses performed on adequate sample size (7 * # items and ≥100) AND Cronbach’s alpha(s) calculated per dimension AND Cronbach’s alpha(s) between 0.70 and 0.95;

? No factor analysis OR doubtful design or method;

– Cronbach’s alpha(s) <0.70 or >0.95, despite adequate design and method.

Reliability (test-retest) The extent to which scores for participants who have not changed are the same for repeated measures over time Terwee et al (2007) + ICC or weighted Kappa ≥ 0.70;

? Doubtful design or method (e.g., time interval not mentioned);

– ICC or weighted Kappa < 0.70, despite adequate design and method.

Content validity The extent to which the domain of interest is comprehensively sampled by the items in the questionnaire Terwee et al (2007) + A clear description is provided of the measurement aim, the target population, the concepts that are being measured, and the item selection AND target population and (investigators OR experts) were involved in item selection;

? A clear description of above-mentioned aspects is lacking OR only target population involved OR doubtful design or method;

– No target population involvement.

Construct validity (hypothesis testing) The extent to which scores on a

particular questionnaire relate to other measures in a manner that is consistent with theoretically derived hypotheses concerning the concepts that are being measured

Terwee et al (2007) + Specific hypotheses were formulated AND the majority of the results are in accordance with these hypotheses;

? Doubtful design or method (e.g., no hypotheses);

– Less than 75% of hypotheses were confirmed, despite adequate design and methods.

Structural validity The degree to which the scores of a (sub) scale are an adequate reflection of the dimensionality of the construct to be measured Exploratory factor analysis – Schellingerhout et al (2012) + Factors explain at least 50% of the variance

? Explained variance not mentioned

– Factors explain <50% of the variance

Confirmatory factor analysis – devised by author + Factor structure confirmed

? Unclear if factor structure confirmed

– Factor structure not confirmed

Notes: ICC: Intraclass correlation; + positive rating; ? indeterminate rating; – negative rating.

Appendix 4. Table 5 Ratings for methodological quality and measurement properties

Methodological quality rated using COSMIN and measurement properties rated using Appendix 3 Table 4

Internal consistency Internal consistency (i) Reliability Reliability Content validity Content validity Structural validity Structural validity (ii)
  Author(s) Methodological quality Measurement property Methodological quality Measurement property Methodological quality Measurement property Methodological quality Measurement property
SCCS Ishiyama & Munsun (1993) Sample (1) Fair [+ Negative self-processing: 0.89; Failure in positive self-processing: 0.77] Poor ? Fair [+ NSP = 43%; FPSP = 9.1%]
SCCS Ishiyama & Munsun (1993) Sample (2) Fair [? $ Test-retest reliability – r138 = 0.83 for total sample; r81 = 0.82 for males; r57 = 0.86 for females. TI: 6.5 weeks]
LSCS Thompson & Zuroff (2004) Study (1) Fair [+ CSC 0.81; ISC 0.87] Poor ? Fair [?]
ATSS Carver & Ganellen (1983) Sample (1) Fair [- Self-criticism: 0.65] Poor ? Fair [- 40%]
ATSSR Carver et al (1988) Study (1) Fair [- Self-criticism: 0.65] Poor ? Fair [CFA +]
ATSSR Carver et al (1988) Study (2 ) & (4 ) (data combined) Poor [? $ Test-retest correlations – Self-criticism: 0.59.TI: 6 weeks]
TPQ Parker et al (2006) Sample (1) Fair [? Cronbach alphas – ranged from 0.62 to 0.91 (Individual subscales not reported)] Poor ? Fair [+50%]
TPQ Parker et al (2006) Sample (2) Poor [ ? ICCs recorded for each subscale – Self-criticism: 0.73 (p<0.001). TI: mean  = 29 days (range 5 – 150 days)]
FSCRS Gilbert et al (2004) Fair [+ IS: 0.90; RS: 0.86; HS: 0.86] Poor ? Fair [+ 58.32%]
FSCRS Kupeli et al (2013) Sample (1) Fair (Items 4, 18 & 20 removed due to low factor loadings) [+ IS = 47.52; HS = 8.8%; RS = 6.74%]
FSCRS Kupeli et al (2013) Sample (2) Fair [+ 18-items – IS: 0.90; RS: 0.88; HS: 0.83. Original 22-items – IS: 0.91; RS: 0.88; HS: 0.86] Fair (Items 4, 18, 20 & 22 removed due to low factor loadings) [CFA +]
FSCRS Baião et al (2015) Fair [+ Non-clinical – IS: 0.90; RS: 0.85; HS: 0.85. Clinical – IS: 0.91; RS: 0.85; HS: 0.87] Fair [CFA +]
SCS Neff (2003) Study (1) – content validity Poor ?
SCS Neff (2003) Study (1) – main study Fair [+ Self-judgement = 0.77] Fair [?]
SCS Neff (2003) Study (2) Poor [? $ Test-retest reliability –  Self-judgement = 0.88. TI: 3 weeks] Fair [?]
SCS Williams et al (2014) Sample (1) Fair [? Self-judgement = 0.8] Excellent [CFA -]
SCS Williams et al (2014) Sample (2) Fair [? Self-judgement = 0.82] Excellent [CFA -]
SCS Williams et al (2014) Sample (3) Fair [? Self-judgement = 0.78] Good [CFA -]
ICARUS Kamholz et al (2006) Study (1) Good [? Self-Criticism/Self-Blame = 0.81] Poor Good [?]
ICARUS Kamholz et al (2006) Study (2A) Good [? Self-criticism/self-blame = 0.83]
ICARUS Kamholz et al (2006) Study (3) Poor [? Self-criticism/self-blame = 0.85] Poor [? $ Test-retest reliability correlation coefficients – self-criticism/self-blame = 0.65 (p<0.001). TI: 1 month] Poor [+73.5%]
HINT Verplanken (2006) Study (2) Poor [? 0.95. (No FA)]
HINT Verplanken et al (2007) Study (1) Poor [? 0.943. (No FA)] Poor ?
HINT Verplanken et al (2007) Study (4) Poor [? 0.945. (No FA)]
HINT Verplanken et al (2007) Study (5) Poor [? 0.947. (No FA)]
HINT Verplanken et al (2007) Study (8) Poor [? 0.955. (No FA)] Poor [? $ Test -retest reliability = 0.801 (p<0.01). TI: 9 months]
SCRS Smart, Peters & Baer (2015) Study (1) Excellent +
SCRS Smart, Peters & Baer (2015) Study (2) Fair [+ 0.92.] Fair [+ 58.4%]
SCRS Smart, Peters & Baer (2015) Study (3) Fair [CFA +]
SCRS Smart, Peters & Baer (2015) Study (4) Fair [? $ Test-retest correlation = 0.86 (& no statistical difference found between scores). TI: 13 -37 days]

Notes: ATSS: Attitudes Towards Self Scale; ATSR: Attitudes Towards Self Scale-Revised; CSC: Comparative self-criticism; FSCRS: Forms of Self-Criticising/Attaching and Self-Reassuring Scale; HINT: Habit Index of Negative Thinking; HS: Hated self; ICARUS: Inventory of Cognitive Affect Regulation Strategies; ICS: Internalised self-criticism; IS: Inadequate self; LSCS: Levels of Self-Criticism Scale; RS: Reassured self; SCCS: Self-Critical Cognition Scale; SCRS: Self-Critical Rumination Scale; SCS: Self-Compassion Scale; TPQ: Temperament & Personality Questionnaire;

CFA: Confirmatory factor analysis;

ICC: Intraclass correlation coefficient;

TI: Time interval;

T1: Time 1;

T2: Time 2;

$: Statistical test other than what COSMIN recommends;

i:Cronbach’s alpha presented;

ii: percentage of variance explained presented.

Appendix 5. Table 6 Construct validity – ratings for methodological quality and measurement property

Methodological quality rated using COSMIN and measurement properties rated using Appendix 3 Table 4

Questionnaire Author(s) Methodological quality Measurement property (i) Results for scales or self-criticism subscales
SCCS Ishiyama & Munsun (1993) Sample (1) Poor ? Correlation coefficients (p<0.05) 1. Self-esteem (n = 416) = -0.71. 2. Depression (n = 168) = 0.42. 3. Between group comparison: higher count of negative self-descriptive adjectives in ‘high’ self-critical group (p<0.01).
LSCS Thompson & Zuroff (2004) Study (2) Fair ? Correlation coefficients (P<0.05) for CSC :1. Distress = 0.53; 2. Self-esteem = -0.66;3. Perfectionism-self = 0.21; Perfectionism-other = 0.21; Perfectionism-social = 0.46. For ISC: 1. Distress = 0.44. 2. Self-esteem = -0.52.3. Perfectionism-self = 0.45. Perfectionism-other = 0.24. Perfectionism-social = 0.49.
ATSS Carver & Ganellen (1983) Sample (2) Poor ? Between group comparison (p<0.02): Gender – Males: Mean = 15.08 (SD = 3.19); Females: Mean = 15.79 (SD = 3.43)
ATSSR Carver et al (1988) Study (2 ) & (4 ) (data combined) Poor ? Correlation coefficients (*p<0.05 **p<0.01) Depression (study sample 2) = 0.15*; (study sample 4) = 0.26**.
ATSSR Carver et al (1988) Study (4) (subset of participants) Poor ? No results presented
ATSSR Carver et al (1988) Study (5) (depression group) Poor ? No results presented
ATSSR Carver et al (1988) Study (5) (whole patient group) Poor ? No results presented
FSCRS Gilbert et al (2004) Fair + Correlation coefficients (* = <0.05; ** =<0.01)  for IS: 1. Depression = 0.52*; 2. ISC = -0.77**. CSC = 0.63**. For HS: 1. Depression = 0.57**. 2. ISC = 0.45**. CSC = 0.55**.  For RS: 1. Depression = -0.51**. 2. ISC = -0.45**. CSC = -0.63**
FSCRS Kupeli et al (2013) Sample (3) Fair + Correlation coefficients (**p<0.001) 18-item FSCRS 1. Happiness – RS = -0.66**; HS = -0.66**; IS = -0.60**. 22-item FSCRS  1. Happiness –  RS = -0.66**; HS = -0.66**; IS = -0.62**. 2. Between group comparison with 18-item version: Gender – females – **IS Mean = 18.3 (SD = 6.4); **RS Mean = 22.2 (SD = 6.8); HS Mean = 9.0 (SD = 4.9). Males – **IS Mean = 16.3 (SD = 6.5); **RS Mean = 20.6 (SD = 7.0);  HS Mean = 8.5 (SD = 4.4)
FSCRS Baião et al (2015) Fair ? 1. Between group comparison (**p = 0.000):  **RS – Clinical: Mean = 10.68 (SD = 6.51); Non-clinical: Mean = 20.27 (SD = 5.77). **IS Clinical: Mean = 27.47 (SD = 7.51); Non-clinical: Mean = 17.72 (SD = 8.29). **HS Clinical: Mean = 12.26 (SD = 5.67); Non-clinical: Mean = 3.88 (SD = 4.59). 2. Between group comparison: No significant differences found for gender in clinical population. Gender in non-clinical population – **RS – males: Mean = 21.20 (SD = 5.27); females: Mean = 19.98 (SD = 5.90) **IS – males: Mean = 16.42 (SD = 7.44); females: Mean = 18.11 (SD = 8.50). **HS – males: Mean = 3.36 (SD = 3.71); females Mean = 4.05 (SD = 4.83) (p = .058)
SCS Neff (2003) Study (1) – main study Fair + Between group comparison (p<0.005) – Gender – Males Mean = 3.00 (SD = 0.81). Females Mean = 3.24 (SD = 0.77)
SCS Neff (2003) Study (2) Fair + No results presented
SCS Neff (2003) Study (3) Fair + Between group comparison (p<0.001) – Buddhist Mean = 2.20 (SD = 0.65); Students Mean 3.07 (SD = 0.82)
ICARUS Kamholz et al (2006) Study (1) Poor ? Between group comparison – Gender – 2×15 (gender by strategy) repeated measures ANOVA completed. No significant interactions found.
ICARUS Kamholz et al (2006) Study (2A) Fair ? Mood induction experiment to test predictive validity – no correlations presented.
ICARUS Kamholz et al (2006) Study (2B) Poor ? Between group comparison – Gender – 2×15 (gender by strategy) repeated measures ANOVA completed. No significant interactions found.
ICARUS Kamholz et al (2006) Study (3) Fair + Correlation coefficients (*p<0.05 **p<0.01 ***p<0.001) 1. Depression = 0.60***; 2. Anxiety = 0.57***
HINT Verplanken (2006) Study (2) Fair + Correlation coefficients (**P<0.001) 1. Past frequency of ‘negative self-thinking’ = 0.648**. 2. Self esteem = -0.737**. 3. Depressive/anxiety symptoms = 0.571**.
HINT Verplanken et al (2007) Study (1) Fair + Task used to test hypotheses (Story & thought-listing protocol). HINT correlated significantly with negative self-thoughts (r = 0.295, p<0.001). Correlation between HINT and negative self-thoughts was significantly different to HINT and general negative thoughts (z = 2.02, p<0.05).
HINT Verplanken et al (2007) Study (4) Fair + Correlation coefficients (p<0.001) 1. Rumination = 0.665; 2. Self-esteem = -0.555
HINT Verplanken et al (2007) Study (5) Fair + Corelation coefficients (**p<0.01, ***p<0.001) 1. ‘Negative self-thinking’ = 0.537***; 2. Explicit self-esteem = -0.473***; 3. Implicit self-esteem = -0.279**
SCRS Smart, Peters & Baer (2015) Study (2) Fair + Correlation coefficients (*p<0.05; **p<0.01) 1. Rumination = 0.81**; 2. Brooding = 0.68**. 3. Rumination-anger = 0.67**; 4. Rumination-anxiety = 0.59**; 5. Rumination-interpersonal = 0.53**; 6. Rumination-social situations = 0.65**; 7. Self-criticism = 0.81**; 8. Shame (different measures) = 0.55**; 0.66**; 0.73**; 9. Self-compassion = -0.62**; 10. Depression/anxiety = 0.58**

Notes: ATSS: Attitudes Towards Self Scale; ATSR: Attitudes Towards Self Scale-Revised; CSC: Comparative self-criticism; FSCRS: Forms of Self-Criticising/Attaching and Self-Reassuring Scale; HINT: Habit Index of Negative Thinking; HS: Hated self; ICARUS: Inventory of Cognitive Affect Regulation Strategies; ICS: Internalised self-criticism; IS: Inadequate self; LSCS: Levels of Self-Criticism Scale; RS: Reassured self; SCCS: Self-Critical Cognition Scale; SCRS: Self-Critical Rumination Scale; SCS: Self-Compassion Scale; TPQ: Temperament & Personality Questionnaire.

(i)  + Specific hypotheses were formulated AND the majority of the results are in accordance with these hypotheses;

? Doubtful design or method (e.g., no hypotheses);

– Less than 75% of hypotheses were confirmed, despite adequate design and methods.

Service Related Project

 

 

 

The recovery rates of older adults in Southwark Psychological Therapies Service (SPTS)

 

 

 

 

 

 

 

 

 

 

 

 

First supervisor: Dr Grace Wong

Contents

Abstract………………………………………………………

1. Introduction………………………………………………….

1.1 Aging population…………………………………………..

1.2 Prevalence of depression and anxiety in older adults……………………

1.3 Cognitive Behavioural Therapy (CBT) for older adults……………………

1.3.1 Evidence-base for CBT for depression in older adults…………………

1.3.2 Evidence-base for CBT for anxiety in older adults……………………

1.3.3 Counselling and Interpersonal Psychotherapy (IPT) for older adults……….

1.3.4 Summary of evidence base of psychological interventions for older adults…..

1.4 Improving Access to Psychological Therapies (IAPT)…………………….

1.4.1 IAPT treatment options……………………………………

1.4.2 IAPT calculating recovery…………………………………..

1.4.3 Access of older adults to IAPT………………………………..

1.5 Southwark Psychological Therapies Service (SPTS)……………………..

1.5.1 Older adults in SPTS………………………………………

1.5.2 Patient screening protocol at SPTS…………………………….

1.5.3 Improving access for older adults in SPTS………………………..

1.5.4 Treatment options offered at SPTS…………………………….

1.6 Aims and hypotheses………………………………………..

1.7 Service user involvement……………………………………..

2. Method…………………………………………………….

2.1 Design………………………………………………….

2.2 Measures……………………………………………….

2.2.1 Patient Health Questionnaire (PHQ-9)…………………………..

2.2.2 Generalised Anxiety Disorder (GAD-7)…………………………..

2.2.3 Work and Social Adjustment Scale (WASAS)………………………

2.3 Data collection…………………………………………….

2.4 Participants………………………………………………

2.5 Data Extraction……………………………………………

2.6 Data analysis……………………………………………..

2.6.1 Referrals……………………………………………..

2.6.2 Demographic information………………………………….

2.6.3 Provisional diagnosis……………………………………..

2.6.4 Recovery rates…………………………………………

2.6.5 Pre and post scores………………………………………

3. Results……………………………………………………..

3.1 Referrals………………………………………………..

3.1.1 Whole service………………………………………….

3.1.2 Older adults…………………………………………..

3.2 Demographic information……………………………………..

3.3 Provisional diagnoses………………………………………..

3.4 Recovery rates of the whole service and older adults……………………

3.5 Recovery rates of older adults who completed different treatment options……..

3.6 Proportion of older adults who completed different treatment options………..

3.7 Statistical tests on pre and post scores for older adults………………….

3.7.1 PHQ-9……………………………………………….

3.7.2 GAD-7……………………………………………….

3.7.3 WASAS………………………………………………

4. Discussion…………………………………………………..

4.1 Access rate………………………………………………

4.2 Opt-in rate……………………………………………….

4.3 Recovery rate of older adults…………………………………..

4.4 Recovery rates of older adults and the whole service……………………

4.5 Recovery rates of older adults who completed different treatment options……..

4.5.1 Step 3 treatment………………………………………..

4.5.2 Guided self-help………………………………………..

4.5.3 Groups and workshops……………………………………

4.6 Proportion of older adults who completed different treatment options………..

4.7 Statistical tests on pre and post scores for older adults………………….

4.8 Limitations………………………………………………

4.9 Leadership……………………………………………….

4.10 Dissemination of results……………………………………..

4.11 Conclusions……………………………………………..

5. References…………………………………………………..

6. Appendices contents page

Appendix 1: Excel formula used to confirm OA labels

Appendix 2 Q-Q plots and Histograms for patient’s first and last scores on the PHQ-9, GAD-7 & WASAS…..

Appendix 3: Matrixes for PHQ-9, GAD-7 & WASAS………………………….

List of Tables

Table 1 Treatment options offered at SPTS

Table 2 Options selected for referral count reports

Table 3 Ethnicity of older adults who completed the assessment stage at SPTS

Table 4 Provisional diagnosis of older adults who completed the assessment stage at SPTS

Table 5 Options selected for caseness/recovery reports

Table 6 Example table provided by IAPTus from a caseness/recovery report

Table 7 Recovery rate information for the whole of SPTS

Table 8 Recovery rate information for older adults

Table 9 Recovery rate information for older adults who completed step 2 guided self-help

Table 10 Recovery rate information for older adults who completed step 2 groups and workshops

Table 11 Recovery rate information for older adults who completed step 3 individual therapy

Table 12 Proportion of older adults who completed different treatment options

Abstract

Introduction

The population in the UK is aging, and there are therefore a significant number of older adults (OAs) who require mental health interventions.  Although there is a growing evidence-base for psychological interventions for this clinical population, older adults are still under-represented in mental health services such as IAPT.  This study had two specific aims which focused on the recovery rates of older adults in SPTS, an IAPT service.

Method

A retrospective case note review was completed using the data that was routinely collected by clinicians between 2008 and 2014.  Data about the number of referrals received, completed assessments, demographic information, recovery rates, and clinical outcome measures for different treatment options were included in the analyses.  Data was included about OAs, as well as the service as a whole.

Results

The first aim of this study compared the recovery rates of OAs for different treatment options.  The recovery rate was 49% for step 3 treatment, 57% for step 2 guided self-help and 40% for step 2 groups and workshops.  In terms of the proportion of OAs completing each treatment option, 72% of OAs completed step 3 treatments, 18% completed guided self-help and 10% completed step 2 groups and workshops.  The overall recovery rate was 50% (meeting national target) for OAs and 39% for the whole service.

The second aim used Wilcoxon signed-rank tests to compare pre and post scores for OAs who either started treatment below the IAPT clinical cut-off or who ended treatment above this cut off.  This study found a significant difference between pre and post scores for OAs who started treatment below caseness, whereas no significant differences were found for OAs who finished treatment above caseness.

 

Conclusions

Older adults who complete treatment at SPTS show significant improvement in their clinical presentation.  In line with the growing evidence-base OAs predominately complete step 3 treatment.  Despite a lower proportion of OAs completing step 2 guided self-help, patients who completed this treatment option show good clinical outcomes.  It may be useful for future research to pilot further ways of engaging OAs in step 2 treatments, including groups and workshops.

1. Introduction

 

1.1 Aging population

Globally, the population is rapidly aging (WHO, 2013).  In the UK, over the last 25 years the number of individuals aged 65 and over has increased by 1.7 million (Office for National Statistics, 2012).  Although promoting and improving wellbeing is important for all ages, the increased number of older adults (OAs) has produced a specific patient group requiring both physical and mental health interventions.

 

1.2 Prevalence of depression and anxiety in older adults

There has been much debate about the prevalence mental health problems (MHPs) in this population (Bryant, 2010).  Some have suggested that rates of depression in OAs are lower than rates reported for working aged adults (Blazer, 2010).  For example, a survey carried out by the Office for National Statistics found that OAs were less likely to have MHP compared to other sections of the population.  It found that 10.2% of individuals aged 65-69 and 9.4% of individuals aged 70-74 had a MHP, compared with 16.4% of the general population (Singleton et al., 2000).  Similarly, according to the Adult Psychiatric Morbidity Survey (McManus et al., 2009) the prevalence of anxiety and depression is lowest in individuals aged 75 and older.  This survey is particularly important to consider as the targets that IAPT services have are calculated based on its results.

On the other hand, these rates may be related to other factors.  Older adults more commonly present with ‘subsyndromal’ or ‘subclinical’ depression (which is thought to be a risk factor for a full blown depressive episode) (Lyness, 2008).   Also, OAs may be less comfortable in discussing emotions and therefore less likely to report mental health symptoms leading to underreported rates of MHPs (Pachana, 2008).

 

1.3 Cognitive Behavioural Therapy (CBT) for older adults

CBT is the recommended treatment for both anxiety and depression (NICE, 2011).  It is been suggested that CBT for depression can be enhanced for OAs by using a comprehensive conceptualisation framework (CCF) (Laidlaw, Thompson & Gallager-Thompson, 2004).  This framework combines the standard CBT longitudinal formulation with possible challenges faced by OAs.  These additional factors include cohort beliefs: the beliefs held by shared by individuals of the same generation; transition in role investments: the transitioning between roles, for example, from professional employment to retirement; intergenerational linkages: the importance of family values passed between generations; socio-cultural context: societal beliefs about ageing, and physical health: consideration of physical health problems that are more common in OAs.

 

1.3.1 Evidence-base for CBT for depression in older adults

In a Cochrane review, Wilson, Mottram & Vassilas (2009) found that CBT was more effective than the control conditions.  The overall conclusion was that “CBT may be of potential benefit” (P. 2).  Similarly, Gould, Coulson & Howard (2012a) conducted a meta-analysis focused on CBT for depression in OAs.  It included 23 randomised controlled trials (RCTs) and 1083 participants with a mean age of 68.4.  The review concluded that CBT was more effective than both a wait-list control and treatment as usual (TAU).  However, CBT was not found to be more effective than other treatment (such as medication or other psychotherapeutic approaches).

In another meta-analysis, pharmacotherapy and psychotherapeutic approaches yielded comparable effect sizes (Pinquart, Duberstein & Lyness, 2006).  In a systematic literature review, Cuijpers et al (2009) compared the treatment outcomes of OAs in comparison to younger people.  Interestingly, they found no significant difference between these two age groups.

 

1.3.2 Evidence-base for CBT for anxiety in older adults

Gould, Coulson & Howard (2012b) conducted a meta-analysis to review the magnitude and duration of factors associated with the effects of CBT for anxiety in OAs.  12 studies were included in the review.  Although it found that CBT was more effective than both a wait-list control and treatment as usual (TAU), when compared to an active control condition, there was not a statistically significant difference between groups.

1.3.3 Counselling and Interpersonal Psychotherapy (IPT) for older adults

In an evidence-based review, Scogin et al (2005) suggest that as well as CBT there are other treatment modalities that may be useful for OAs.  In a more recent meta-analysis, Pinquart et al (2007) found that CBT is more effective than other treatment options including physical exercise, IPT and ‘miscellaneous’ interventions (e.g. music therapy).  They suggest that more controlled studies focused on the effectiveness of IPT, psychodynamic and supportive interventions are needed before making recommendations on their use in OAs.

 

1.3.4 Summary of evidence base of psychological interventions for older adults

Taken as a whole, these results suggest that CBT is an effective form treatment for both depression and anxiety in OAs (both compared to TAU and other treatment approaches). It is important to note however that fewer studies have examined the effects of delivery method on therapeutic outcomes in OAs.  It could be that OAs respond differently to CBT depending on whether it is delivered in a group or within individual sessions.  This is particularly relevant when considering the context in which CBT is delivered in the NHS; through IAPT services.

1.4 Improving Access to Psychological Therapies (IAPT)

In 2006 Lord Layard published The Depression Report, highlighting the need for increased access to psychological therapies (Layard, 2006).  The UK Government responded to this with a large-scale initiative to improve mental health outcomes (DoH, 2011a; 2011b).  More specifically, IAPT services were first piloted (Clark et al., 2009; Richard & Suckling, 2009) and then rolled out nationwide.

 

1.4.1 IAPT treatment options

IAPTs offer interventions recommended by the National Institute for Clinical Excellence (NICE), focusing primarily on CBT.  Treatment is provided within a system of stepped-care. IAPTs are therefore made up of step 2 (low-intensity) and step 3 (high-intensity) treatment options.  Step 2 treatment options include guided self-help and computerised CBT, and are delivered by Psychological Wellbeing Practitioners (PWPs).  The main step 3 treatment option is individual CBT.  IAPT services also offer group treatment options and workshops.

 

1.4.2 IAPT calculating recovery

At every contact with an individual during treatment in an IAPT service, outcome measures are collected (IAPT, 2011).  The outcome measures make up what is known as the Minimum Data Set (MDS).  The MDS includes the Patient Health Questionnaire (PHQ-9), a measure of depression (Kroenke, Spitzer & Williams, 2001); the Generalised Anxiety Disorder (GAD-7), a measure of anxiety (Spitzer, Kroenke, Williams & Löwe, 2006), and the Work and Social Adjustment Scale (WASAS), a measure of impact on daily functioning (Mundt, Marks, Shear & Greist, 2002) .

The data collected from the MDS is used to calculate recovery rates.  More specifically, in IAPT services, recovery rates are calculated in terms of ‘caseness’; in order to count as ‘recovered’ patients must score above a certain threshold pre-treatment, and then move to below this at the end of treatment.  Caseness is defined as 10 and above on PHQ-9 or 8 and above on GAD-7.  Patients must then be below caseness on both measures to count as ‘recovered’.  The exception will be when there is an ADSM (Anxiety Disorder Specific Measure) used at two contacts, in which case the first occurrence and last occurrence of the ADSM define the first and last sessions for calculating caseness at start and finish using the PHQ-9 and ADSM. The recovery rate is then presented as a percentage representing what proportion of individuals ‘recovered’ according to these criteria.  The national recovery rate target for IAPT services is 50% (Clark & Oates, 2014).

 

There are a number of possible limitations with this method of calculating recovery.  Firstly, patients may reach the threshold for caseness, and by moving 2 points on the measures, reach recovery; one could therefore question whether this patient has actually ‘recovered’.  Secondly, thinking specifically about OAs, because they may more commonly present with ‘subsyndromal’ or ‘subclinical’ depression (Lyness, 2008), they may never reach caseness and therefore their recovery rates would not be included in analysis. Finally another limitation of this approach is that an individual who scored at the severe range of depression and / or anxiety at the start of treatment can achieve a clinically significant drop in scores at the end of the therapy without them falling within the non-case range.

 

1.4.3 Access of older adults to IAPT

Despite the development of IAPT services, it is thought that only 1 in 6 of OAs with depression discuss it with their GP, and less than half get adequate treatment (Chew-Graham, Burns & Baldwin, 2004).  Furthermore, data from IAPT first-wave sites showed that OAs only represented 4% of those accessing the services (the expected national rate given the age profile of the population and the community prevalence of depression and anxiety disorders, would be 12% (DoH, 2011c)).  Thus, OAs have been underrepresented in IAPT services (Clark, 2011).

More recently, the UK Government has recognised this discrepancy between the rates of OAs with anxiety and depression, and the rates of these individuals accessing IAPTs. It has invested around 400 million between 2011-2015 to specifically focus on expanding provision  for underrepresented patient groups, of which OAs is one of them (HM Government, 2011; DoH, 2011b).  Also, an Older People Positive Practice Guide was published (IAPT, 2009).  With this in mind, it is essential for IAPT services to monitor the care offered to OAs.  This study focused on the treatment options and recovery rates of OAs at Southwark Psychological Therapies Service (SPTS), an IAPT service.

1.5 Southwark Psychological Therapies Service (SPTS)

SPTS became an IAPT service in 2008.  It provides psychological interventions to individuals experiencing anxiety and/or depression.  Individuals must be a minimum of 18 years old, live in Southwark and / or register with a Southwark GP.  More specifically, SPTS is divided into four localities: North East, North West, South East and South West.

1.5.1 Older adults in SPTS

Prior to 2008, OAs in Southwark had access to the Southwark Older Adults Primary Care Psychology Service (SOAPCPS) (Wong & Boddington, 2011).  This was funded by the Guys & St Thomas’s Charitable Foundation between November 2004 and February 2008 (and then by the corresponding NHS Trust for another 8 months).  The service was a uni-disciplinary psychology service that was tailored specifically to the needs of OAs.

In 2008, the SOAPCPS was merged with SPTS (Wong & Boddington, 2011).  Estimations suggest that 24,259 OAs live in the catchment area of SPTS (GLA, Round Population Projections, 2007).  Over the first 2 year period (from November 2008 to June 2010) SPTS reported that 4.4% of its referrals were adults aged 65 years old and above (Wong, 2010).  The SPTS Annual Report (April 2010 – March 2011) suggests that adults aged 60 years old are under-represented in SPTS referrals: “those 65 and older are estimated to form 10.92% of the adult population in Southwark, but they only formed 3.60% of referrals to SPTS in 2010 – 2011.” (Wingrove et al., 2011, P. 55).  The Equality of Access (EoA) represents the percentage of OAs seen in a service divided by the percentage of adults aged 65 and above in the local adult population.  In SPTS the EoA has been calculated to be 33% (Boddington, 2011).

On the other hand, the SPTS Annual Report also highlights that this method of estimating EoA does not take account of the relative prevalence of common MHPs in different age groups.  Using the data from the proportion of older people among the adult population in Southwark (10.92%) and the Adult Psychiatric Morbidity Survey (prevalence rate for common mental health disorders for OAs = 4.46%), the estimate for Southwark access rate would be 7.5% (see SPTS Annual Report for further information about calculations).

 

1.5.2 Patient screening protocol at SPTS

Since 2008, the patient screening and assessment protocol has changed a number of times according to resources and service demands.  Of note, these protocols have always included the use of an opt-in pack that individuals send into SPTS at the beginning of treatment.

In order to improve access for OAs, SPTS developed a different screening protocol specifically for this age group.  The major difference in this screening process is that OAs are not required to complete an opt-in pack.  Upon receiving a referral, the individual is screened by the OA lead.  The OA lead offers the individual either a telephone or face-to-face assessment.  The individual is also able to choose where this face-to-face assessment takes place; at an out-patient clinic, in a GP surgery or during a home visit.  In another words, SPTS has been proactive in making sure that the barrier to access service for OAs are kept to a minimum. The MDS is collected during the initial assessment, and treatment options are discussed.

 

1.5.3 Improving access for older adults in SPTS

As well as providing a specific protocol for OAs entering SPTS, this IAPT service have put in place a number of other measures to increase access.  These include:

  • Offering home visits when appropriate;
  • Adjusting treatment sessions in terms of pace, length, frequency and total number;
  • Assisting OAs in the completion of MDS if needed;
  • Training to step 2 and step 3 staff.

 

1.5.4 Treatment options offered at SPTS

The treatment options offered at SPTS are listed in Table 1.

Table 1 Treatment options offered at SPTS

Step Individual Groups Workshops
Step 2 Guided self-help
  • Panic
  • Behavioural Activation
  • ‘Back on Track’ (for anxiety and depression)
  • Mindfulness
  • Mindfulness Based Stress Reduction (MBSR) for Long Term Conditions and Medically Unexplained Symptoms (LTC/MUS)
  •  Anxiety and Depression for LTC/MUS
  • Compassion and

Relaxation

  • Stress
  • Confidence
  • Sleep
  • Anger
Step 3 Individual therapy sessions

1.6 Aims and hypotheses

This study had two specific aims.  The first aim focused on OAs and the different treatment options offered within SPTS.  Specifically, it compared the recovery rates of OAs who received different treatment options.  In this study, because of the way the data was extracted and analysed, comparisons were made between step 3 treatment, step 2 guided self-help and step 2 groups and workshops.  The proportion of OAs who took part in each treatment option was also calculated.   Finally, as part of aim 1, the overall recovery rate for OAs was calculated and compared to the recovery rate of the whole service.

For aim 1, it was predicted that:

  • Recovery rates for OAs would be higher for step 3 treatment in comparison to step 2 treatment options;
  • A larger proportion of OAs would have taken part in step 3 treatment.
  • Overall OAs would benefit from treatment as well as younger adults; thus recovery rates would be similar.

The second aim looked at a different method of calculating the MDS scores for OAs who have completed treatment in SPTS.  It used statistical tests to calculate whether there is a significant difference between pre and post PHQ-9, GAD-7 and WASAS scores for OAs. For this aim, no specific hypotheses were made.

1.7 Service user involvement

When conducting research, service user involvement is crucial (Wallcraft et al., 2009).  In relation to this study, the aims and hypotheses were presented and discussed at the SPTS Service User Forum.

2. Method

2.1 Design

This study was a retrospective case note review.

 

2.2 Measures

IAPTs use the Minimum Data Set (MDS) to calculate recovery rates.  This consists of a number of outcome measures.  The three specific outcome measures used in this study are detailed below.

2.2.1 Patient Health Questionnaire (PHQ-9)

The PHQ-9 is a measure of depression (Kroenke, Spitzer & Williams, 2001).  The PHQ-9 has 9 items describing symptoms of depression, for example, “feeling down, depressed, or hopeless”.  Patients rate their agreement on a 4-point likert scale ranging from “Not at all” to “Nearly every day”.  A score is given out of 27, with higher scores representing a more severe depression.  More specifically, the PHQ-9 provides a depression index score:

  • 0-4 – None
  • 5-9 – Mild
  • 10-14 – Moderate
  • 15-19 – Moderately Severe
  • 20-27 – Severe

In IAPT, caseness is defined as having a score on the PHQ-9 of 10 and above.

2.2.2 Generalised Anxiety Disorder (GAD-7)

The GAD-7 is a measure of anxiety (Spitzer, Kroenke, Williams & Löwe, 2006).  It has 7 items detailing symptoms of anxiety, for example “feeling nervous, anxious or on edge”.  Patients rate their agreement on a 4-point likert scale ranging from “Not at all” to “Nearly every day”.  A score is given out of 21, with higher scores representing a more severe anxiety.  The GAD-7 also provides an anxiety index score:

  • 0-4 – None
  • 5-10 – Mild Anxiety
  • 11-15 – Moderate Anxiety
  • 15-21 – Severe Anxiety

In IAPT, caseness is defined as having a score on the GAD-7 of 8 and above.

2.2.3 Work and Social Adjustment Scale (WASAS)

The WASAS measures the impact of a patient’s mental health problem on different areas of their lives (Mundt, Marks, Shear & Greist, 2002).  There are 5 items, each focused on a different area of functioning: work, home management, social leisure activities, private leisure activities, and family and relationships.  Patients rate their agreement on a 8-point likert scale ranging from “Not at all” to “Very severely”.  A score is given out of 40, with higher scores representing a more impaired levels of functioning.

 

2.3 Data collection

This study used data that had been collected between 01/11/2008 and 28/02/2014.  The data had been collected from patients as part of routine practice and stored on IAPTus, an online, password protected database that is used to store and analyse patient information.

2.4 Participants

IAPT defines older adults (OAs) as those aged 65 and older. Thus, before any analysis was completed, every patient file was checked to confirm that all OAs had an OA referrallabel.   In order to do this, the patient database was extracted from IAPTus into Excel, and then an Excel formula was used to confirm that all patients aged 65 and older had an OA referral label (see Appendix 1 for details).

2.5 Data Extraction

Once all OAs had been confirmed to have an OA referral label, information about these patients were extracted from IAPTus for the data analyses.  IAPTus automatically only extracts patients who have finished treatment at SPTS.  It is important to note however that IAPTus defines ‘finished treatment’ as patients who had a minimum of two MDS scores taken at two different time points.  Thus, the patients extracted could have either completed a treatment option, dropped out of a treatment option,  or completed two assessment appointments where two separate MDSs were recorded, but did not go on to have actual treatment.

2.6 Data analysis

In order to analyse the data, both IAPTus Hypercube and SPSS were used.  IAPTus Hypercube was initially used to run a number of reports.  Data about referrals, demographic information, provisional diagnosis, recovery rates, proportion of OAs who completed different treatment options, and pre and post scores were included in the analyses.

SPSS was then used to analyse the pre and post scores on the PHQ-9, GAD-7 and WASAS.  Normality was tested for the PHQ-9, GAD-7 and WASAS separately by inspecting the data distribution using a Q-Q plot and histogram (see Appendix 2).  Visual inspection suggested that the data sets were not normally distributed.  Because of this, the non-parametric Wilcoxon signed-rank test was used.

2.6.1 Referrals

This study reports the number of referrals received and the number of referrals accepted in SPTS for the whole service, as well as specifically for OAs.  It also reports the number of referrals who entered and completed the assessment stage at SPTS. This information was then used to calculate the opt-in rates for the whole service and both the opt-in and access ratesfor OAs.

2.6.2 Demographic information

This study reports the demographic information (age range, gender and ethnicity) of OAs who completed the assessment stage at SPTS.

2.6.3 Provisional diagnosis

This study reports the provisional diagnoses of OAs who completed the assessment stage at SPTS.

2.6.4 Recovery rates

This study reports the overall recovery rate for the whole service and specifically for OAs.  It then reports separate OA recovery rates for each treatment option.  The following treatment options were selected: step 2 guided self-help; step 2 groups and workshops, or step 3 individual therapy.  It is important to note that if patients received more than 1 treatment option in one episode (for example, stepped up from step 2 to step 3, stepped down from step 3 to step 2, or given a different treatment option within the same step), IAPTus automatically includes their MDS scores in the recovery rate analysis for both options.

2.6.5 Pre and post scores

IAPTus defines pre-scores as the first MDS collected.  IAPTus defines post-scores in two ways; either the clinician selects the ‘End of Treatment’ tab on the patient’s clinical contact, or if this has not been selected, the last MDS score is used. As mentioned, the exception will be when there is an ADSM (Anxiety Disorder Specific Measure) used at two contacts, in which case the first occurrence and last occurrence of the ADSM define the first and last sessions for calculating caseness at start and finish using the PHQ-9 and ADSM.

3. Results

3.1 Referrals

Firstly, ‘referral count’ reports were run using IAPTus Hypercube to calculate the number of referrals received and the number of referrals accepted for the whole service and specifically for older adults (OAs).  For these reports, the options that were selected are listed in Table 2.  For the reports focused on OAs, an ‘older adult’ referral label was also selected.

In order to calculate the number of referrals who entered and completed the assessment stage at SPTS a ‘referral count’ report was run (selecting the same options as in Table 2), and the option ‘assessment attended’ was added as a filter.

Table 2 Options selected for referral count reports

From Date: 01/11/2008
To Date: 28/02/2014
Treatment Type: IAPT

 

3.1.1 Whole service

It was found that SPTS received 27433 referrals.  Of these, 25479 individuals were accepted into the service.  It was found that 16292 patients completed the assessment stage.

To work out the opt-in rate of patients in SPTS the number of patients who entered and completed the assessment stage was divided by the number of patients accepted into the service.  Thus, the opt-in rate was calculated to be 64% ((16292/25479)*100).

3.1.2 Older adults

It was found that SPTS received 853 OA referrals.  Of these, 776 OAs were accepted into the service.  It was found that 582 OAs completed the assessment stage.

To work out the opt-in rate of OAs in SPTS the number of OAs who entered and completed the assessment stage was divided by the number of OAs accepted into the service.  Thus, the opt-in rate was calculated to be 75% ((585/776)*100).

To work out the access rate for OAs the number of OAs who completed the assessment stage was divided by the number of completed assessments by the whole service.  Thus, the access rate was calculated to be 3.58%.

3.2 Demographic information

The demographic information of OAs who completed the assessment stage was then calculated.  This was done by running separate ‘referral count’ reports selecting the same information as in Table 2 and selecting the ‘group by’ function (i.e. group by age range, gender and ethnicity).

The age range was 63– 100.  403 were female and 179 were male.  The percentage breakdown of ethnicity is displayed in Table 3 (missing data was excluded).

 

Table 3 Ethnicity of older adults who completed the assessment stage at SPTS

Ethnicity Percentage of patients
White 85.8
Mixed race 1.0
Asian/British Asian 3.1
Black 6.6
Other 2.7
Unwilling to disclose 0.8

Regarding the age range, it was identified that there was 1 patient aged 36 years old who had an ‘older adult’ label wrongly attached to it.    Although there is no way of identifying which patient this is using IAPTus, because the demographic information relates to those who completed the assessment stage, it may be that the patient did not enter treatment and therefore may not affect the recovery rate analysis.  There were also a handful of 63 and 64 years old patients wrongly labelled as OAs.

 

3.3 Provisional diagnoses

The breakdown of provisional diagnoses for OAs who completed the assessment stage are displayed in Table 4 (missing data was excluded).  As described above, a ‘referral count’ report was run selecting the same information as in Table 2 and then selecting the ‘group by’ function (i.e. group by provisional diagnosis).

Table 4 Provisional diagnosis of older adults who completed the assessment stage at SPTS

Provisional diagnosis Percentage of patients
Mental and behavioural disorders due to use of alcohol 0.4
Depressive episode 29.7
Recurrent depressive disorder 15.8
Agoraphobia (with or without history of panic disorder 2.9
Specific (isolated) phobias 4.8
Generalised anxiety disorder 9.9
Mixed anxiety and depressive disorder 17.6
Obsessive-compulsive disorder 1.5
Post-traumatic stress disorder 2.2
Somatoform disorders 0.7
Mental disorder, not otherwise specified 4.0
Disappearance and death of family member 3.3
Panic disorder (episodic paroxysmal anxiety) 2.9
Adjustment disorders 2.9
Hypochondriacal disorder 0.7
Reaction to severe stress or adjustment disorders 0.7

 

3.4 Recovery rates of the whole service and older adults

A ‘caseness/recovery’ report was run to calculate the overall recovery rate for the whole service, as well as specifically for OAs.  For these reports, the options that were selected are listed in Table 5.

 

Table 5 Options selected for caseness/recovery reports

From Date: 01/11/2008
To Date: 28/02/2014
First Stage Entered: Referral
Treatment Type: IAPT

As described previously, in IAPT services, recovery rates are calculated in terms of ‘caseness’. It is therefore important to emphasise that in order to be included in the recovery rate analyses patients must have started treatment above caseness on both the PHQ-9 and GAD-7 and come down below caseness on both of these outcome measures (with the exception of ADSM as outlined before).  The recovery rate is then presented as a percentage representing what proportion of individuals ‘recovered’ according to this criteria.

After a ‘caseness/recovery’ report is run, IAPTus presents the information in a table (see Table 6for description of each cell).  Using Table 6,recovery rates were calculated by dividing the number of patients who ‘recovered’ (those who met caseness at the beginning of treatment and were below caseness at the end of treatment) by the total number of patients who met caseness.  This number was then multiplied by 100 to turn it into a percentage.

Table 6 Example table provided by IAPTus from a caseness/recovery report

  Last measure to caseness Last measure to recovery Total
First measure from caseness Number of patients who met caseness at the beginning and end of treatment Number of patients who met caseness at the beginning of treatment and were below caseness at the end of treatment (i.e. ‘recovered’) Total number of patients who met caseness at the beginning of treatment
First measure from recovery Number of patients who were below caseness at the beginning of treatment and met caseness at the end of treatment Number of patients who were below caseness at the beginning and end of treatment Total number of patients who were below caseness at the beginning of treatment
Total Total number of patients who met caseness at the end of treatment Total number of patients who were below caseness at the end of treatment Total number of patients who completed treatment

 

Table 7 shows the recovery rate information for the whole of SPTS.  Using this table, the recovery rate was calculated to be 39% ((3652/9319)*100).

Table 7 Recovery rate information for the whole of SPTS

  Last measure to caseness Last measure to recovery Total
First measure from caseness 5667 3652 9319
First measure from recovery 350 1633 1983
Total 6017 5285 11302

As the second report focused on the recovery rate of OAs, the referral label of ‘OA’ was selected before another ‘caseness/recovery’ report was run.  Table 8 shows the recovery rate information for OAs in SPTS.  Using this table, the recovery rate was calculated to be 50% ((150/298)*100).

 

Table 8 Recovery rate information for older adults

  Last measure to caseness Last measure to recovery Total
First measure from caseness 148 150 298
First measure from recovery 6 79 85
Total 154 229 383

3.5 Recovery rates of older adults who completed different treatment options

The specific first aim of this study was to compare recovery rates for OAs who completed different treatment options.  In order to calculate separate recovery rates, a number of ‘caseness/recovery’ reports, selecting a ‘treatment type’ filter, and then specifically selecting one of the 3 treatment options.

Table 9 shows the recovery rate information for OAs who completed step 2 guided self-help.  Using this table, the recovery rate was calculated to be 57% ((28/49)*100).

Table 9 Recovery rate information for older adults who completed step 2 guided self-help

  Last measure to caseness Last measure to recovery Total
First measure from caseness 21 28 49
First measure from recovery 3 24 27
Total 24 52 76

Table 10 shows the recovery rate information for OAs who completed step 2 groups and workshops.  Using this table, the recovery rate was calculated to be 40% ((10/25)*100).

 

Table 10 Recovery rate information for older adults who completed step 2 groups and workshops

  Last measure to caseness Last measure to recovery Total
First measure from caseness 15 10 25
First measure from recovery 1 16 17
Total 16 26 42

 

Table 11 shows the recovery rate information for OAs who completed step 3 individual therapy.  Using this table, the recovery rate was calculated to be 49% ((117/238)*100).

Table 11 Recovery rate information for older adults who completed step 3 individual therapy

  Last measure to caseness Last measure to recovery Total
First measure from caseness 121 117 238
First measure from recovery 4 55 59
Total 125 172 297

3.6 Proportion of older adults who completed different treatment options

In order to work out the proportion of OAs who completed different treatment options the total number of patients included in each recovery rate analysis for each treatment option were compared, and turned into a percentage (See Table 12).

Table 12 Proportion of older adults who completed different treatment options

Treatment option Total number of patients Proportion of OAs
Step 2 guided self-help 76 18%
Step 2 groups and workshops 42 10%
Step 3 individual therapy 297 72%
Total 415 100%

3.7 Statistical tests on pre and post scores for older adults

Aim 2 focused on comparing the traditional method of calculating recovery rates in IAPT with using t-tests to calculate whether there is a significant difference between pre and post scores on the PHQ-9, GAD-7 and WASAS.  In order to extract the relevant patient data from IAPTus, Hypercube was used.  A ‘Pre and Post Matrix’ was selected, and either ‘PHQ-9’, ‘GAD-7’ or ‘WASAS’ were selected in the data field.  IAPTus therefore produced separate matrixes for each outcome measure.  The matrixes show the number of patients who had different combinations of first and last scores (see Appendix 3for the original matrixes).  Excel was then used to manipulate the data structure from the Matrixes into columns of pre and post data for individual patients.

As normality tests suggested that the data sets were not normally distributed (see Appendix 2), the non-parametric Wilcoxon signed-rank test was used.

 

3.7.1 PHQ-9

Firstly, a Wilcoxon signed-rank test were performed to compare pre and post scores on the PHQ-9.  The Wilcoxon signed-rank test showed that there was a significant difference in the pre and post scores on the PHQ-9 [z = -11.30, N = 384, p < 0.01]. Scores had significantly decreased at the end of treatment (M = 7.88, SD = 6.43), in comparison to the beginning of treatment (M = 11.89, SD = 5.98).  Thus, OAs had decreased low mood after treatment at SPTS.

For the PHQ-9, patients were then selected who began treatment below caseness (a score of 9 and below).  A Wilcoxon signed-rank test showed that there was a significant difference in the pre and post scores for these patients [z = -4.10, N = 143, p < 0.01].  Scores had significantly decreased at the end of treatment (M = 4.55, SD = 4.29), in comparison to the beginning of treatment (M = 5.72, SD = 2.51).  Thus, OAs who began treatment below caseness had decreased low mood after treatment at SPTS.

Patients were then selected who finished treatment above caseness on the PHQ-9 (a score of 10 and above).  A Wilcoxon signed-rank test showed that there was not a significant difference in the pre and post scores for these patients [z = -0.19, N = 123, p = ns].  Scores did not significantly decrease at the end of treatment (M = 15.74, SD = 4.63), in comparison to the beginning of treatment (M = 15.74, SD = 5.16).  Thus, OAs who finished treatment above caseness did not show significant decreases in low mood.

3.7.2 GAD-7

Secondly, a Wilcoxon signed-rank test were performed to compare pre and post scores on the GAD-7.  The Wilcoxon signed-rank test showed that there was a significant difference in the pre and post scores on the GAD-7 [z = -12.00, N = 383, p < 0.01]. Scores had significantly decreased at the end of treatment (M = 6.39, SD = 5.52), in comparison to the beginning of treatment (M = 10.39, SD = 5.64).  Thus, OAs had decreased level of anxiety after treatment at SPTS.

For the GAD-7, patients were then selected who began treatment below caseness (a score of 7 and below).  A Wilcoxon signed-rank test showed that there was a significant difference in the pre and post scores for these patients [z = -4.09, N = 135, p < 0.01].  Scores had significantly decreased at the end of treatment (M = 3.18, SD = 3.26), in comparison to the beginning of treatment (M = 4.23, SD = 2.19).  Thus, OAs who began treatment below caseness had decreased levels of anxiety after treatment at SPTS.

Patients were then selected who finished treatment above caseness on the GAD-7 (a score of 8 and above).  A Wilcoxon signed-rank test showed that there was not a significant difference in the pre and post scores for these patients [z = -1.81, N = 127, p = 0.07].  Scores did not significantly decrease at the end of treatment (M = 13.09, SD = 3.79), in comparison to the beginning of treatment (M = 13.84, SD = 4.43).  Thus, OAs who finished treatment above caseness did not show significant decreases in levels of anxiety.

 

3.7.3 WASAS

Finally, a Wilcoxon signed-rank test was used to compare pre and post scores on the WASAS.  The Wilcoxon signed-rank test showed that there was a significant difference in the pre and post scores on the WASAS [z = -9.14, N = 382, p < 0.01].  Scores had significantly decreased at the end of treatment (M = 8.18, SD =7.92), in comparison to the beginning of treatment (M = 11.74, SD = 8.39).  Thus, OAs had improved in functioning after treatment at SPTS.

4. Discussion

The first aim of this study focused on comparing the recovery rates of older adults (OAs) who had completed different treatment options.  As part of this aim the proportion of OAs who completed each treatment option was also calculated, as well as comparing the overall OA recovery rate to that of the whole service.

The second aim focused on comparing two methods for calculating OA recovery rates; the traditional IAPT method based on caseness, and using statistical tests to look for significant differences between pre and post scores on the IAPT outcome measures.

Before the specific aims of this study are discussed, the access rate and opt-in rate for OAs will be commented on.

4.1 Access rate

This study calculated the access rate for OAs was 3.58%, which is below the OA target access rate of 7.5%.  This result highlights that this national target (but locally adapted) for OAs is not currently being met by SPTS.  It suggests that it may be important for SPTS to consider ways of increasing the access rate for OAs.  For example, it may be helpful to assess the feasibility of increasing the advertising of SPTS in places that are likely to be frequented by OAs such as in GP surgeries, libraries or day centres.  Also, it may be useful to consider sessions for GPs and clinicians in secondary care to describe referral criteria and processes for OAs into SPTS.  These initiatives may lead to increases in the number of referrals into SPTS thus potentially increasing the access rate.

4.2 Opt-in rate

This study calculated the opt-in rate for OAs was 75% in comparison to an opt-in rate of 64% for the whole service.  This suggests that once an OA is accepted into SPTS, they are likely to complete the initial assessment stage.    This result may be linked to the screening and assessment protocol that SPTS uses for OA. For example, reducing the barrier to access SPTS by offering home visit and not requiring OAs to complete the opt-in pack may increase the likelihood of an OA completing the assessment stage.

4.3 Recovery rate of older adults

The overall recovery rate for OAs in SPTS of 50% meets the national recovery rate target for IAPT services (Clark & Oates, 2014).  Furthermore, the Wilcoxon signed-rank test which compared pre and post scores on the IAPT outcome measures confirmed a significant improvement at the end of completed treatment.  This suggests that when these patients complete treatment, they are likely to have good therapeutic outcomes regardless of the treatment option they receive.  Clinicians at SPTS are therefore meeting the needs of OAs who access the service, and that OAs find the psychological interventions offered at SPTS useful.

 

4.4 Recovery rates of older adults and the whole service

This study predicted that OAs would benefit from treatment as well as younger adults, meaning that the recovery rates would be similar.  However, against this prediction, this study found the overall recovery rate was 39% for the whole service and 50% for OAs.

There are a number of potential factors that could be related to the differences in recovery rates for the two groups.  Firstly, in relation to the Older People Positive Practice Guide (IAPT, 2009), it could be that clinicians think more consciously about the possible appropriate adaptations when treatment OAs.  These might include a slower pace during sessions, or a greater number of longer sessions.  This individualised approach to treatment might then lead to good outcomes with this age group. One angle for future research to explore this idea further could be using qualitative methods to interview clinicians at SPTS to look for any differences in the treatment approach taken when working with an OA in comparison to a younger patient.

Another aspect to consider is the typical treatment option that an OA would be offered at SPTS.  It could be that OAs entering the service are more likely to be offered a step 3 intervention, whereas a young adult with comparable symptom severity would be offered a step 2 treatment option first, leading to overall potentially better outcomes for the OAs. This idea is discussed in more detail further on.

4.5 Recovery rates of older adults who completed different treatment options

This study predicted that recovery rates for OAs would be higher for step 3 treatments in comparison to step 2 treatment options.  This prediction was partially upheld.  Specifically, recovery rates were 49% for step 3 treatment, 57% for step 2 guided self-help and 40% for step 2 groups and workshops.  Thus, the step 3 recovery rate was higher than step 2 groups but lower than step 2 guided self-help (as highlighted in the limitations section no statistical tests were performed on these figures).

4.5.1 Step 3 treatment

The recovery rate for step 3 treatment does indicate that CBT (and other step 3 interventions such as IPT) are potentially beneficial for OAs.  One limitation with calculating an overall recovery rate for step 3 treatment is that it does not distinguish between different treatment options.  It is known that the majority of OAs who complete step 3 are provided with a CBT intervention, since the majority of clinicians are trained in this psychological modality.  However, it may be useful in the future for the service to have more detailed information in regards to the effectiveness of, for example, CBT compared with IPT.

This study found a lower recovery rate for step 3 treatment in comparison to guided self-help.  It is possible that this difference is related to the patient characteristics of those who take part in each treatment option.  Step 3 interventions are aimed at patients with moderate or severe anxiety and/or depression, and who are likely to have been suffering with related symptoms for a longer period of time.  Because of this, it may be more difficult to see change in the symptoms that are measured by IAPT outcome measures such as the PHQ-9 and the GAD-7.  Patients may also be less motivated to change (McCullough, 2003), or be more likely to drop out early (Persons, Burns & Perloff, 1988).  It is also possible that patients may require a greater number of sessions to produce the symptomatic change that is required to be included in the recovery analysis.

Conversely, patients who were offered guided self-help would be more likely to have mild/moderate anxiety and/or depression, meaning that their symptoms would be less severe and enduring, possibly leading to a larger rate of recovery.

4.5.2 Guided self-help

The recovery rate of guided self-help suggests that when OAs complete this treatment option at SPTS, over 50% recover. Guided self-help typically involves patients working through a “standardised psychological treatment protocol” based on the principles of CBT (Cuijpers & Schuurmans, 2007, P. 284) with the support of a Psychological Wellbeing Practitioner (PWP).

Research focused on working-aged adults has produced favourable outcomes.  In a large meta-analysis, Hirai & Clum (2006) found that several self-help formats were moderately effective for participants with certain anxiety disorders.  Spek et al (2007) specifically focused on internet-based CBT for OAs (defined as aged 50 and above).  They found that there was a larger effect size for the internet-based intervention in comparison to a waitlist control group.  Interestingly there is a stronger evidence-base for guided self-help in comparison to pure self-help (Gellatly et al., 2007), suggesting that the therapeutic alliance between patient and therapist is important.  This may be particularly important for OAs; they may respond particularly well to one-to-one contact with a clinician.

Another aspect to consider in regards to guided self-help that may be particularly relevant for the OA population is the flexibility in appointment structure that it allows for.  Older adults are more likely to suffer with a long term physical health problem (Department of Health, 2012).   Thus, guided self-help may increase access to certain patients who wouldn’t normally access the service due to physical disability (Nutting et al., 2002).

4.5.3 Groups and workshops

This study calculated the OA recovery rate for step 2 groups and workshops was 40%.  This contrast in recovery rates for guided self-help and groups and workshops may be related to the different methods of delivery of these two step 2 intervention types.

 

Older adults may benefit from one-to-one interactions with a clinician.  For example, when explaining Behavioural Activation for depression, a PWP would explain this strategy using examples specifically relating to a patient.  In contrast, within groups and workshops it is likely that more generic examples would be used. Furthermore, the content of groups and workshops may not include aging related worries such as retirement or loss of social network.

One final point to bear in mind is the difference in structure of these treatment options.  Step 2 groups and workshops at SPTS tend to run over 6-8 90 minutes sessions and day-long session respectively.  Whereas guided self-help involves up to 8 sessions (telephone or face to face) which last around between 30 minutes.  It may be that OAs benefit more from this style of delivery.

In light of these results, it could be useful to think about how to make groups more engaging for OAs.  For example, in the future SPTS could think about the feasibility of developing a group specifically for this population, and possibly offering it at a day centre.

4.6 Proportion of older adults who completed different treatment options

In line with predictions made that a larger proportion of OAs would have taken part in step 3 treatment.  This study found that 72% of OAs completed step 3 treatments, 18% completed guided self-help and 10% completed step 2 groups.  Decisions about treatment are usually made collaboratively between clinician and patient, and there are a number of potential reasons why the majority of OAs are offered step 3 treatments.

It could be that when thinking about appropriate treatment options clinicians use the current evidence-base to guide their decisions.   At present, very few research trials have focused specifically on the use of step 2 treatment options for OAs.  Thus, clinicians may be more inclined to offer step 3 treatments.

It is also important to note the possible influence of stereotypes from both the clinician and patient perspective.  Clinicians may have a stereotype of an OA who for example may not be as familiar with technology such as the internet (needed for computerised CBT), or preferring the structure of a ‘traditional’ face-to-face therapy, and therefore are less likely to offer a step 2 treatment option.  Similarly, an OA may have an understanding of therapy based on the assumption of individual and face to face sessions, and therefore they may be less likely to engage with other therapy formats.  It could be helpful for SPTS to think about how to advertise step 2 treatment options for OAs by for example developing specific materials that introduce them to each treatment option available.

4.7 Statistical tests on pre and post scores for older adults

Aim 2 focused on comparing the traditional method of calculating recovery rates in IAPT with using statistical tests to calculate whether there is a significant difference between pre and post scores on the PHQ-9, GAD-7 and WASAS.  For this aim, no specific hypotheses were made.

Firstly, this study selected patients who began treatment below caseness on either the PHQ-9 or the GAD-7.  This study found significant differences on both the PHQ-9 & GAD-7 in these patients.   Caseness is defined as 10 and above on PHQ-9 (Kroenke, Spitzer & Williams, 2001) and 8 and above on GAD-7 (Spitzer, Kroenke, Williams & Löwe, 2006). Those who begin treatment below caseness could therefore still be in the mild ranges on both outcome measures.  The significant difference between pre and post scores may be related to the fact that mild depression and anxiety are more responsive to treatment, resulting in a bigger different in these two sets of scores.

Secondly, this study also selected patients who completed treatment above caseness on either the PHQ-9 or the GAD-7.  This study found no significant differences between the pre and post scores on either the PHQ-9 or the GAD-7 in this sub-set of patients.  The explanation for this could be the converse reason for the significant different in pre and post scores for patients who start treatment below caseness; patients may be experiencing moderate to severe depression and anxiety which may be less responsive to treatment, leading to less movement on the quantitative outcome measures.  It could be that the maximum number of sessions offered to patients at step 3 may not be adequate to shift more entrenched negative or thoughts anxious or beliefs about themselves.

4.8 Limitations

The major limitation of this study is related to drawing firm conclusions about why there were differences found between recovery rates between OAs and the whole service.  These conclusions are limited due to differences in sample sizes, as well as the fact that the two groups of patients (the whole service compared to OAs) were not matched on personal characteristics such as ethnicity, provisional diagnosis or symptom severity. A similar limitation applies to making interpretations about the differences in recovery rates for different treatment options.  Older adults were assigned to different treatment options based on their presenting needs, and the groups were not matched as they would be in a controlled research trial.  Furthermore, because of the way that IAPTus extracts data, this study was unable to calculate whether the difference between the recovery rates for different treatment options was statistically significant.

Another limitation is related to the way that IAPTus records patient information.  For example, on IAPTus a patient’s final scores on the MDS are used in the recovery rates analyses.  This does not therefore distinguish between patients who have completed treatment, and those who have dropped out.  This could be particularly relevant for the analysis in this study that focused on patients who completed treatment above caseness; this sub-set of patients may be more likely to drop out which may account for the lack of significant difference between pre and post scores.

4.9 Leadership

There were leadership opportunities at the beginning stage of this project.  On commencing the placement at SPTS I sought out a project on OAs because of my interest in this clinical population.  I discussed project ideas with both my placement supervisor and then the OAs lead for the service.  Furthermore, I researched opportunities with the trust to discuss research ideas with service users.

In terms of potential leadership opportunities going forward SPTS could think about further potential ways to engage OAs in step 2 treatment options.  For example, staff members could design leaflets giving information about each treatment option.  SPTS also could assess the acceptability and feasibility of designing a treatment group or workshop specifically for OAs.

 

4.10 Dissemination of results

The findings of the study were disseminated in a number of ways:

  • The findings were summarised and communicated to the Lead of the service;
  • The report summary was included in the monthly service information e-bulletin;
  • A copy of the final report was saved onto the service shared drive within ‘older adults resources’;
  • Summaries of results will be included in future SPTS whole service reports.

 

4.11 Conclusions

Overall, the treatment offered to OAs at SPTS does produce significant improvements in patients.  This study found differences between the recovery rates of OAs for different treatment options.  Although fewer number of OAs complete step 2 guided self-help, the OA recovery rate was highest for this treatment option.  This suggests that OAs respond well to using a one-to-one structured treatment programme with the support of a psychological wellbeing practitioner.  Future investigations at SPTS may be useful to pilot ways of improving the uptake of this treatment option in OAs, as well as improving the engagement of OAs in other step 2 groups and workshops.  When using statistical tests to calculate recovery, this study found a significant difference in pre and post scores for OAs who were below caseness at the beginning of treatment, but no significant differences in OAs who were above caseness at the end of treatment.

5. References

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6. Appendices contents page

 

Appendix 1: Excel formula used to confirm OA labels

Appendix 2: Q-Q plots and Histograms for patient’s first and last scores on the PHQ-9, GAD-7 & WASAS

Appendix 3: Matrixes for PHQ-9, GAD-7 & WASAS

 

Appendix 1: Excel formula used to confirm OA labels

  • Export the patient database from IAPTUS to Excel.
  • Create column header named: Age at Admission and in the cell below insert this formula:
    • =DATEDIF(Date of Birth Cell,Date Referral Received Cell,”y”)
  • Create column header named Older Adult and in the cell below insert the formula:
    • =IF(Age of Admssion Cell>=65,”Older Adult”,FALSE)
  • Export the “OA” labelled patients from IAPTUS to the same Excel sheet.
  • Create column header named Label and in the cell below insert the formula:
    • =IF(COUNTIF(column where the labelled patients’ ID is, cell where the first patient’s ID is in the big database),IF(Older Adult Cell=”Older Adult”,”Labelled”,”Check Multi-Ref”),IF(Older Adult Cell=”Older Adult”,”Label Needed”))

Appendix 2 Q-Q plots and Histograms for patient’s first and last scores on the PHQ-9, GAD-7 & WASAS

 

Q-Q Plots for scores on the PHQ-9 at the beginning of treatment

Histogram for scores on the PHQ-9 at the beginning of treatment

 
Q-Q plot for scores on the PHQ-9 at the end of treatment

Histogram for scores on the PHQ-9 at the end of treatment

Q-Q plot for scores on the GAD-7 at the beginning of treatment

Histogram for scores on the GAD-7 at the beginning of treatment

 

Q-Q plot for scores on the GAD-7 at the end of treatment

Histogram for scores on the GAD-7 at the end of treatment

Q-Q Plot for scores on the WASAS at the beginning of treatment

Histogram for scores on the WASAS at the beginning of treatment

Q-Q Plot for scores on the WASAS at the end of treatment

Histogram for scores on the WASAS at the end of treatment

Appendix 3: Matrixes for PHQ-9, GAD-7 & WASAS

Matrix for PHQ-9

Matrix for GAD-7

Matrix for WASAS

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