Main Research Project, Systematic Review & Service Related Project
Contents Page
Main Research Project……………………………………………….Page 3
Systematic Review………………………………………..…………..Page 178
Service Related Project………………………………………………Page 249
Main Research Project
Self-criticism: Development of a new intervention
Contents
Abstract………………………………………………………
1. Introduction………………………………………………….
1.1 Self-criticism……………………………………………….
1.2 The treatment of self-criticism……………………………………
1.3 Constructs related to self-criticism and their treatment……………………
1.3.1 Perfectionism……………………………………………
1.3.2 Self-esteem…………………………………………….
1.3.3 Depressive rumination……………………………………..
1.4 Self-compassion interventions to target self-criticism…………………….
1.5 Student mental health…………………………………………
2. Aims……………………………………………………….
2.1 Hypotheses………………………………………………..
3. Method…………………………………………………….
3.1 Ethical Approval…………………………………………….
3.2 Design……………………………………………………
3.3 Participants………………………………………………..
3.4 Measures…………………………………………………
3.4.1 Primary outcome measures…………………………………..
3.4.2 Secondary outcome measures…………………………………
3.4.3 Process measures…………………………………………
3.4.4 Measures to aid formulation………………………………….
3.4.5 Participant feedback……………………………………….
3.5 Procedure…………………………………………………
3.6 Intervention……………………………………………….
3.7 Feasibility & acceptability objectives………………………………..
3.8 Data preparation and analysis……………………………………
3.8.1 Hypotheses 1 & 2: Feasibility & acceptability……………………….
3.8.2 Hypotheses 3, 4 & 5: Changes in self-criticism and other outcomes…………
3.8.2.1 Therapist effects……………………………………….
3.8.2.2 Effects of waiting for intervention……………………………
3.8.2.3 Comparison between pre and post-intervention…………………..
3.8.2.4 Associations with reductions in self-criticism…………………….
4. Results……………………………………………………..
4.1 Participant demographic information……………………………….
4.2 Hypothesis 1: Feasibility………………………………………..
4.2.1 Recruitment and retention…………………………………..
4.2.2 Inclusion / exclusion criteria…………………………………..
4.3 Hypothesis 2: Acceptability……………………………………..
4.3.1 Acceptability of assessment methods…………………………….
4.3.2 Acceptability of the intervention……………………………….
4.3.2.1 The intervention as a whole……………………………….
4.3.2.2 Treatment rationale…………………………………….
4.3.2.3 Psycho-education components……………………………..
4.3.2.4 Acceptability and use of specific techniques……………………..
4.3.2.5 Session attendance……………………………………..
4.4 Treatment protocol: fidelity & revisions……………………………..
4.4.1 Fidelity………………………………………………..
4.4.2 Protocol revisions…………………………………………
4.5 Changes in self-criticism and other outcomes………………………….
4.5.1 Therapist effects………………………………………….
4.5.2 Effect of waiting time for intervention……………………………
4.5.3 Hypotheses 3 and 4: Comparison between pre and post-intervention……….
4.5.3.1 Hypothesis 3A, 4 & 5: Primary outcome measures…………………
4.5.3.2 Hypothesis 3B, 4 & 5: Secondary outcome measures……………….
4.5.3.3 Hypothesis 3C, 4 & 5: Comparison between pre and post-intervention for process measures
4.5.3.4 Hypothesis 3C: Associations with reductions in self-criticism…………..
5. Discussion…………………………………………………..
5. 1 Hypothesis 1: Feasibility……………………………………….
5.2 Hypothesis 2: Acceptability……………………………………..
5.2.1 Acceptability of assessment methods…………………………….
5.2.2 Acceptability of the intervention……………………………….
5.3 Hypotheses 3, 4 & 5: Changes in self-criticism and other outcomes and associations between the changes…..
5.3.1 Impact on self-criticism and associated impairment…………………..
5.3.2 Changes in secondary outcome measures………………………….
5.3.3 Changes in process measure………………………………….
5.4 Limitations………………………………………………..
5.5 Strengths…………………………………………………
5.6 Implications……………………………………………….
5.7 Conclusions………………………………………………..
References
Appendices contents page…………………………………………..
Appendix 1. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) original approval (18.11.2014)…..
Appendix 2. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) modification approval (27.02.2015)…..
Appendix 3. Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) modification approval (16.07.2015)…..
Appendix 4. Questionnaires completed at each time point…………………..
Appendix 5. Study questionnaires…………………………………..
Appendix 6. Participant feedback questionnaire…………………………
Appendix 7. Measure of frequencies of use of specific intervention techniques since end of treatment collected at two-month follow-up appointment…..
Appendix 8. Flow chart to show participants’ journey and involvement of therapists
Appendix 9. Online recruitment advertisement………………………….
Appendix 10. Participant information sheet……………………………
Appendix 11. Participant consent form……………………………….
Appendix 12. Session protocols……………………………………
Appendix 13. Blank participant formulation worksheet…………………….
Appendix 14. Participant booklets………………………………….
Appendix 15. Post-intervention ratings of how useful participants found the intervention
Appendix 16. Post-intervention ratings of how useful participants found each technique
Appendix 17. Ratings of frequency of use for each technique since end of treatment collected at follow-up appointment…..
Appendix 18. Results of independent t-tests comparing the two therapists on participant measures across time points…..
Appendix 19. Results of linear regressions investigating relationship between (a) length of baseline (time between screening and pre-intervention), (b) time from screening to post-intervention and (c) time from pre to post intervention and change in study measures…..
Appendix 20. Line graphs for secondary outcome measures (PHQ-9, GAD-7, RSES and ‘maladaptive perfectionism) at main study time points…..
Appendix 21. Line graphs for process measures (SCS, ERQ-reappraisal, ERQ-suppression, and BES) at main study points…..
List of Tables
Table 1 Feasibility objectives and outcomes
Table 2 Acceptability of assessment methods and intervention
Table 3 Participant baseline demographic information
Table 6 Process measures: Results of one-way ANOVAs, means and standard deviations and effect sizes
List of Figures
Figure 1 Study flow diagram showing recruitment process
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.
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).
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.
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.
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.
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.
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.
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).
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:
It was hypothesized that:
Ethical approval was gained from the King’s College London (KCL) Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (see Appendices 1, 2 and 3).
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).
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 |
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