The ups and downs of self-criticism and disordered eating: Complementing Paranjothy and Wade's (2024) analysis by considering both trait and state perspectives.

Paranjothy and Wade's (2024) meta-review reveals that individuals higher in the personality trait of self-criticism consistently experience more disordered eating than those lower in the trait. The clinical implications of this meta-review are important in that they suggest current theoretical models and clinical practices in the field of eating disorders should incorporate a greater focus on self-criticism. Building on this exciting contribution, we highlight conceptual, practical, and empirical reasons why the field would benefit from supplementing this research on trait self-criticism with investigations of state self-criticism. We review research showing that self-criticism levels vary not only between individuals, with some people chronically more self-critical than others, but also within a person, with a given individual enacting relatively more self-criticism during some moments and days than others. We then present emerging research showing that these periods of higher-than-usual self-criticism are associated with more disordered eating. Thus, we emphasize the need to explore the factors that give rise to self-critical states in daily life, and review preliminary findings on this topic. We highlight the ways in which research on within-person variations in self-criticism can complement research on trait self-criticism to advance case formulation, prevention, and treatment in the field of eating disorders.

Self-compassion promotes positive mental health in women with anorexia nervosa: A two-week daily diary study.

Despite the importance of positive mental health, little is known about its facilitators in people with eating disorders (EDs). Drawing on past research, we hypothesized that self-compassion might be a contributing factor to positive mental health in individuals with EDs. In a two-week daily diary study of women (N = 32) with anorexia nervosa, we investigated whether self-compassion levels-on average, on a given day, and from one day to the next-predicted social safeness (i.e. a sense of social connection and warmth) and positive affect, both indicators of positive mental health. Multilevel modeling revealed that, controlling for ED symptoms, (1) higher daily self-compassion, (2) increases in self-compassion from the previous day, and (3) higher trait self-compassion, were associated with greater positive affect and social safeness. Findings suggest that in addition to reducing ED symptoms in people with EDs, as documented by prior research, the cultivation of self-compassion might facilitate improved emotional and social well-being in this population.

Alkaline State of the Domain-Swapped Dimer of Human Cytochrome c: A Conformational Switch for Apoptotic Peroxidase Activity.

A 2.08 Å structure of an alkaline conformer of the domain-swapped dimer of K72A human cytochrome c (Cytc) crystallized at pH 9.9 is presented. In the structure, Lys79 is ligated to the heme. All other domain-swapped dimer structures of Cytc have water bound to this coordination site. Part of Ω-loop D (residues 70-85) forms a flexible linker between the subunits in other Cytc domain-swapped dimer structures but instead converts to a helix in the alkaline conformer of the dimer combining with the C-terminal helix to form two 26-residue helices that bracket both sides of the dimer. The alkaline transition of the K72A human dimer monitored at both 625 nm (high spin heme) and 695 nm (Met80 ligation) yields midpoint pH values of 6.6 and 7.6, respectively, showing that the Met80 → Lys79 and high spin to low spin transitions are distinct. The dimer peroxidase activity increases rapidly below pH 7, suggesting that population of the high spin form of the heme is what promotes peroxidase activity. Comparison of the structures of the alkaline dimer and the neutral pH dimer shows that the neutral pH conformer has a better electrostatic surface for binding to a cardiolipin-containing membrane and provides better access for small molecules to the heme iron. Given that the pH of mitochondrial cristae ranges from 6.9 to 7.2, the alkaline transition of the Cytc dimer could provide a conformational switch to tune the peroxidase activity of Cytc that oxygenates cardiolipin in the early stages of apoptosis.

A two-week daily diary study examining the association between daily self-compassion and symptoms of bulimia nervosa.

OBJECTIVES: Individuals with symptoms of bulimia nervosa (BN) are more likely to binge and purge on days of greater negative affect. Given that self-compassion helps individuals cope more adaptively with distress, the present study examined the contribution of daily fluctuations in self-compassion to eating disorder symptoms in women who endorse symptoms of BN. The directionality of these associations was also examined. METHOD: For 2 weeks, 124 women who met the DSM-5 criteria for BN completed nightly measures of their daily eating pathology and self-compassion. RESULTS: Self-compassion levels varied almost as much within a person from day-to-day as between-persons (i.e., from one person to the next). Multilevel modeling revealed that within persons, higher daily levels of self-compassion were associated with a reduced probability of both binge eating and inappropriate compensation, and lower levels of dietary restraint and clinical impairment. Secondary analyses revealed that these variables mutually influenced one another within but not across days. Between persons, higher mean levels of self-compassion over the 2 weeks were associated with less dietary restraint and clinical impairment but were unrelated to binge eating and compensatory behaviors. DISCUSSION: For women who report symptoms consistent with BN, responding to daily distress with greater self-compassion than usual may attenuate the psychosocial and behavioral symptoms of their eating disorder. Similarly, days of reduced eating pathology may facilitate self-compassion. Future research using experimental paradigms and ecological momentary assessments may shed further light on the ways in which self-compassion and eating pathology relate to one another in this population.

Why would I want to be more self-compassionate? A qualitative study of the pros and cons to cultivating self-compassion in individuals with anorexia nervosa.

OBJECTIVE: Although self-compassion facilitates eating disorder symptom remission, individuals with eating disorders are fearful of developing it and higher fears of self-compassion are associated with poorer treatment outcomes. In-depth exploration of individuals' pros and cons of behaviour change is generally helpful at resolving ambivalence; however, no research has examined the pros and cons individuals with eating disorders perceive to be associated with developing self-compassion, limiting our understanding of their personal experiences when confronted with self-compassion. Given the research suggesting higher resistance to self-compassion development in individuals with anorexia nervosa (AN), the present study used qualitative methods to gain a deeper understanding of their perceived pros and cons to self-compassion. METHODS: Thirty-seven women with typical (64%) and atypical (36%) AN signed up for a study on self-help strategies for daily distress. Upon learning that the intervention would entail cultivating self-compassion, they identified their perceived pros and cons of developing self-compassion by typing them out. RESULTS: Thematic analysis was used to extract themes. Three superordinate cons and four superordinate pros of self-compassion emerged. Perceived cons were as follows: self-compassion leading to personal shortcomings; apprehension and doubt about the efficacy of self-compassion; and emotional challenges associated with developing self-compassion. Perceived pros were as follows: improved health; personal development (e.g., growth, coping); improved outlook; and enhanced social relationships. CONCLUSIONS: These findings reveal the various advantages and disadvantages that women with AN perceive to be associated with developing self-compassion. Results may help clinicians work more sensitively and effectively when trying to cultivate self-compassion in patients who have AN. PRACTITIONER POINTS: This research suggests that patients with anorexia nervosa (AN) perceive various disadvantages to cultivating self-compassion, but also certain advantages. By familiarizing themselves with the pros and cons to self-compassion identified by individuals with AN, clinicians may be able to more effectively listen to and communicate with their patients about ambivalence about self-compassion development. Clinicians may want to listen for and explore concerns in their AN patients that self-compassion will lead to personal shortcomings, fail to be beneficial, and be emotionally challenging. Clinicians may want to listen for and help patients elaborate upon their beliefs about how self-compassion might benefit their outlook, health, personal development, and relationships.

Fears of compassion magnify the harmful effects of threat of COVID-19 on mental health and social safeness across 21 countries.

BACKGROUND: The COVID-19 pandemic is a massive global health crisis with damaging consequences to mental health and social relationships. Exploring factors that may heighten or buffer the risk of mental health problems in this context is thus critical. Whilst compassion may be a protective factor, in contrast fears of compassion increase vulnerability to psychosocial distress and may amplify the impact of the pandemic on mental health. This study explores the magnifying effects of fears of compassion on the impact of perceived threat of COVID-19 on depression, anxiety and stress, and social safeness. METHODS: Adult participants from the general population (N = 4057) were recruited across 21 countries worldwide, and completed self-report measures of perceived threat of COVID-19, fears of compassion (for self, from others, for others), depression, anxiety, stress and social safeness. RESULTS: Perceived threat of COVID-19 predicted increased depression, anxiety and stress. The three flows of fears of compassion predicted higher levels of depression, anxiety and stress and lower social safeness. All fears of compassion moderated (heightened) the impact of perceived threat of COVID-19 on psychological distress. Only fears of compassion from others moderated the effects of likelihood of contracting COVID-19 on social safeness. These effects were consistent across all countries. CONCLUSIONS: Fears of compassion have a universal magnifying effect on the damaging impact of the COVID-19 pandemic on mental health and social safeness. Compassion focused interventions and communications could be implemented to reduce resistances to compassion and promote mental wellbeing during and following the pandemic.

Most women with anorexia nervosa report less eating pathology on days when they are more self-compassionate than usual.

OBJECTIVE: Individuals with eating disorders who have lower trait levels of self-compassion have more severe eating pathology. This study examined the extent to which levels of self-compassion fluctuate day-to-day in individuals with anorexia nervosa (AN) and whether these fluctuations contribute to their eating pathology. METHOD: For 2 weeks, 33 women with typical (75%) and atypical AN reported on their daily eating pathology and self-compassion. RESULTS: Nearly half the variance in participants' self-compassion scores occurred at the within-persons daily level. Multilevel modeling revealed that on days when participants were more self-compassionate than usual, their eating pathology was lower. However, this effect was moderated by participants' mean self-compassion level over the 2 weeks. Specifically, daily self-compassion was negatively related to eating pathology among individuals with average and higher mean self-compassion levels but was not related to eating pathology among those with lower levels. DISCUSSION: One-time self-reports of self-compassion in individuals with AN may overlook the substantial within-person variability in their self-compassion levels. For most individuals with AN, responding to distressing daily experiences with more compassion than usual should be associated with decreased eating pathology. More work is needed to understand how individuals lower in dispositional self-compassion can benefit from these upward fluctuations.

The relation between two barriers to self-compassion and clinical characteristics in individuals with eating disorders.

There is growing support for the role of self-compassion in recovery from an eating disorder (ED) and two types of barriers have been identified in this population: (a) fears that self-compassion will result in a failure to meet personal and interpersonal standards (meeting standards); and (b) fears that self-compassion gives rise to difficult emotions such as grief and unworthiness (emotional vulnerability). OBJECTIVE: This research examined the relative contribution of meeting standards and emotional vulnerability barriers to the clinical characteristics of individuals with EDs. METHOD: Participants (N = 349) completed the fears of compassion for self-scale, and measures of self-compassion, ED and psychiatric symptom severity, interpersonal and affective functioning, quality of life and readiness for ED change. RESULTS: Together, the two barrier types accounted for significant variance in all study variables. Meeting standards was associated with lower readiness to change and greater over-control. In contrast, emotional vulnerability was associated with lower self-compassion, readiness, and quality of life, poorer interpersonal and affective functioning, and greater ED and psychiatric severity. CONCLUSION: While both barriers to self-compassion were related to functioning in individuals with EDs, the emotional vulnerability barrier accounted for more variance in pathology and may be most beneficial to target in treatment.

The fragility of perceived social rank following exercise in anorexia nervosa: an ecological momentary assessment study of shame and pride.

PURPOSE: Pride and shame are self-conscious emotions closely associated with perceived social rank. Goss and Gilbert (In: Gilbert and Miles (eds) Body shame: conceptualization, research & treatment. Brunner-Routledge, Hove, 2002) proposed that weight-control behaviours in anorexia nervosa (AN) provide a temporary sense of increased rank that dissipates afterwards, thereby perpetuating further symptoms. This pilot study tested their theory by examining whether shame increases and pride decreases as time passes post-exercise in individuals with AN. Pre-exercise patterns were also explored. METHODS: Over 2 weeks, 23 females with AN provided ecological momentary assessment data via six semi-random daily signals and after each exercise episode. The State Shame and Guilt Scale assessed pride and shame. Items modified from the Experience of Shame Scale and the Other as Shame Scale assessed general shame and body/eating shame. Multilevel models analyzed patterns of shame and pride prior to and following exercise episodes. RESULTS: In the hours after exercise, pride decreased, body/eating shame increased, and general shame increased on one measure. Pride was, therefore, higher and shame lower immediately after exercise as compared to later in the day. In the hours before exercise, pride increased, but shame levels did not change significantly. CONCLUSION: The anticipation and immediate aftermath of exercise may be associated with higher perceived social rank in people with AN, but their feelings about self may worsen as time passes after exercise. Fluctuations in shame and pride may contribute to the maintenance of exercise in people with AN. LEVEL OF EVIDENCE: IV, multiple time series analysis.

A feasibility study of a 2-week self-compassionate letter-writing intervention for nontreatment seeking individuals with typical and atypical anorexia nervosa.

OBJECTIVE: Most individuals with anorexia nervosa (AN) do not seek treatment and shame is a common barrier. This study sought to determine whether a brief intervention designed to foster self-compassion would reduce shame and increase treatment motivation among nontreatment seeking individuals with AN. METHOD: Forty nontreatment seeking females with AN (75%) and atypical AN were randomly assigned to 2 weeks of a daily self-compassionate letter-writing intervention or a waitlist control condition. All participants completed pre, mid, and post questionnaires, and were weighed pre and post. RESULTS: The intervention yielded respectable credibility ratings and compliance and retained 95% of participants. Compared to the control condition, it produced greater increases in self-compassion and greater decreases in shame and fears of self-compassion. BMI and readiness to get help for one's eating decreased in the control condition but did not change significantly in the intervention condition, though the motivation for treatment showed a trend toward increasing. Changes in eating pathology and readiness to get help for one's weight did not differ between conditions. DISCUSSION: Self-compassionate letter-writing may be an acceptable and feasible intervention for nontreatment seeking individuals with AN and might reduce certain barriers to help-seeking while improving psychological functioning.

Group-Based Compassion-Focused Therapy as an Adjunct to Outpatient Treatment for Eating Disorders: A Pilot Randomized Controlled Trial.

The current study sought to assess the acceptability and feasibility of a compassion-focused therapy (CFT) group as an adjunct to evidence-based outpatient treatment for eating disorders, and to examine its preliminary efficacy relative to treatment as usual (TAU). Twenty-two outpatients with various types of eating disorders were randomly assigned to 12 weeks of TAU (n = 11) or TAU plus weekly CFT groups adapted for an eating disorder population (CFT + TAU; n = 11). Participants in both conditions completed measures of self-compassion, fears of compassion, shame and eating disorder pathology at baseline, week 4, week 8 and week 12. Additionally, participants receiving the CFT group completed measures assessing acceptability and feasibility of the group. Results indicated that the CFT group demonstrated strong acceptability; attendance was high and the group retained over 80% of participants. Participants rated the group positively and indicated they would be very likely to recommend it to peers with similar symptoms. Intention-to-treat analyses revealed that compared to the TAU condition, the CFT + TAU condition yielded greater improvements in self-compassion, fears of self-compassion, fears of receiving compassion, shame and eating disorder pathology over the 12 weeks. Results suggest that group-based CFT, offered in conjunction with evidence-based outpatient TAU for eating disorders, may be an acceptable, feasible and efficacious intervention. Furthermore, eating disorder patients appear to see benefit in, and observe gains from, working on the CFT goals of overcoming fears of compassion, developing more self-compassion and accessing more compassion from others. Copyright © 2016 John Wiley & Sons, Ltd.

Within-persons predictors of change during eating disorders treatment: An examination of self-compassion, self-criticism, shame, and eating disorder symptoms.

OBJECTIVE: Attempts to identify the predictors of change during eating disorders treatment have focused almost exclusively on identifying between-persons factors (i.e., differences between patients). Research on within-person predictors of change (i.e., variations within patients over time) may provide novel and clinically useful information. To illustrate, we test the theory that within patients, self-compassion, self-criticism, shame, and eating disorder symptoms reciprocally influence one another over time. METHOD: Seventy-eight patients with an eating disorder completed the Self-Compassion Scale, Experience of Shame Scale, and Eating Disorder Examination Questionnaire every three weeks across 12 weeks of treatment. RESULTS: Multilevel modeling revealed that following periods of increased shame, a patient's eating pathology was more severe than usual. Following periods of increased self-compassion or decreased eating pathology, a patient's level of shame was lower than usual. Between-person differences in the relationships among study variables also emerged. DISCUSSION: Results support the theory that shame and eating pathology influence one another cyclically within patients over time, and suggest that time-dependent increases in self-compassion may interrupt this cycle. If replicated, these results might suggest that assessing and intervening with increases in a patient's level of shame may help to reduce her eating pathology, and improving a patient's level of self-compassion or eating disorder symptomology may lower her subsequent experiences of shame. Findings highlight the value of administering and examining repeatedly measured within-person predictors of change during eating disorders treatment, and suggest that it may be clinically important to attend to the changes that occur within a given patient over time. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:716-722).

Predictors and moderators of between-therapists and within-therapist differences in depressed outpatients' experiences of the Rogerian conditions.

The extent to which patients experience their therapists as providing empathy, positive regard and genuineness (the Rogerian Conditions) is an important predictor of outcome in the psychotherapy of depression (Zuroff & Blatt, 2006). Using data from 157 depressed outpatients treated by 27 therapists in the cognitive-behavior therapy, interpersonal therapy, or clinical management with placebo conditions of the Treatment of Depression Collaborative Research Program (Elkin et al., 1989), Zuroff, Kelly, Leybman, Blatt, and Wampold (2010) showed that between-therapists and within-therapist differences in Rogerian Conditions at the second treatment session predicted more rapid reductions in overall maladjustment. We conducted novel analyses intended to identify: 1) predictors of between-therapists and within-therapist differences in Rogerian Conditions and 2) moderators of the effects on maladjustment of between-therapists and within-therapist differences in Rogerian Conditions. Patients with lower levels of self-critical perfectionism, higher levels of an adaptive form of dependency or higher expectations of warmth from their therapists experienced higher levels of Rogerian Conditions than their therapist's average patient. High baseline self-critical perfectionism diminished the between-therapists effect of Rogerian Conditions on maladjustment, whereas baseline adaptive dependency enhanced the within-therapist effect of Rogerian Conditions. Results shed additional light on the centrality of patient characteristics, the Rogerian Conditions, and their transactions and interactions on outcome in brief outpatient therapy for depression.

Conceptualizing and Measuring Self-Criticism as Both a Personality Trait and a Personality State.

Blatt's ( 2004 , 2008 ) conceptualization of self-criticism is consistent with a state-trait model that postulates meaningful variation in self-criticism both between persons (traits) and within person (states). We tested the state-trait model in a 7-day diary study with 99 college student participants. Each evening they completed a 6-item measure of self-criticism, as well as measures of perceived social support, positive and negative affect, compassionate and self-image goals during interactions with others, and interpersonal behavior, including overt self-criticism and given social support. As predicted, self-criticism displayed both trait-like variance between persons and daily fluctuations around individuals' mean scores for the week; slightly more than half of the total variance was between persons (ICC = .56). Numerous associations at both the between-persons and within-person levels were found between self-criticism and the other variables, indicating that individuals' mean levels of self-criticism over the week, and level of self-criticism on a given day relative to their personal mean, were related to their cognitions, affect, interpersonal goals, and behavior. The results supported the construct validity of the daily self-criticism measure. Moreover, the findings were consistent with the state-trait model and with Blatt's theoretical analysis of self-critical personality.

Autonomous and controlled motivation for eating disorders treatment: baseline predictors and relationship to treatment outcome.

OBJECTIVE: This study aimed to identify baseline predictors of autonomous and controlled motivation for treatment (ACMT) in a transdiagnostic eating disorder sample, and to examine whether ACMT at baseline predicted change in eating disorder psychopathology during treatment. METHOD: Participants were 97 individuals who met DSM-IV-TR criteria for an eating disorder and were admitted to a specialized intensive treatment programme. Self-report measures of eating disorder psychopathology, ACMT, and various psychosocial variables were completed at the start of treatment. A subset of these measures was completed again after 3, 6, 9, and 12 weeks of treatment. RESULTS: Multiple regression analyses showed that baseline autonomous motivation was higher among patients who reported more self-compassion and more received social support, whereas the only baseline predictor of controlled motivation was shame. Multilevel modelling revealed that higher baseline autonomous motivation predicted faster decreases in global eating disorder psychopathology, whereas the level of controlled motivation at baseline did not. CONCLUSION: The current findings suggest that developing interventions designed to foster autonomous motivation specifically and employing autonomy supportive strategies may be important to improving eating disorders treatment outcome. PRACTITIONER POINTS: The findings of this study suggest that developing motivational interventions that focus specifically on enhancing autonomous motivation for change may be important for promoting eating disorder recovery. Our results lend support for the use of autonomy supportive strategies to strengthen personally meaningful reasons to achieve freely chosen change goals in order to enhance treatment for eating disorders. One study limitation is that there were no follow-up assessments beyond the 12-week study and we therefore do not know whether the relationships that we observed persisted after treatment. Another limitation is that this was a correlational study and it is therefore important to be cautious about making causal conclusions when interpreting the results.

Are improvements in shame and self-compassion early in eating disorders treatment associated with better patient outcomes?

Compassion-focused therapy (CFT; Gilbert, 2005, 2009) is a transdiagnostic treatment approach focused on building self-compassion and reducing shame. It is based on the theory that feelings of shame contribute to the maintenance of psychopathology, whereas self-compassion contributes to the alleviation of shame and psychopathology. We sought to test this theory in a transdiagnostic sample of eating disorder patients by examining whether larger improvements in shame and self-compassion early in treatment would facilitate faster eating disorder symptom remission over 12 weeks. Participants were 97 patients with an eating disorder admitted to specialized day hospital or inpatient treatment. They completed the Eating Disorder Examination-Questionnaire, Experiences of Shame Scale, and Self-Compassion Scale at intake, and again after weeks 3, 6, 9, and 12. Multilevel modeling revealed that patients who experienced greater decreases in their level of shame in the first 4 weeks of treatment had faster decreases in their eating disorder symptoms over 12 weeks of treatment. In addition, patients who had greater increases in their level of self-compassion early in treatment had faster decreases in their feelings of shame over 12 weeks, even when controlling for their early change in eating disorder symptoms. These results suggest that CFT theory may help to explain the maintenance of eating disorders. Clinically, findings suggest that intervening with shame early in treatment, perhaps by building patients' self-compassion, may promote better eating disorders treatment response.

Why self-critical patients present with more severe eating disorder pathology: the mediating role of shame.

OBJECTIVES: Gilbert (Compassion: Conceptualisations, Research, and Use in Psychotherapy. London: Routledge, 2005) theorized that self-critical individuals have more severe psychopathology due in part to their elevated feelings of shame. We sought to test this model in a sample of eating disorder sufferers. METHOD: Seventy-four patients admitted to a specialized day or inpatient eating disorders treatment programme completed the Forms of Self-Criticism and Self-Reassurance Scale, Rosenberg Self-Esteem Inventory, Experience of Shame Scale, Beck Depression Inventory, Positive and Negative Affect Schedule, and Eating Disorder Examination Questionnaire. RESULTS: We tested our mediational model with Preacher and Hayes' (Behavior Research Methods, 40, 879, 2008) bootstrapping approach entering self-criticism as a predictor, self-esteem as a covariate, and shame, negative affect, positive affect, and depressive symptoms as simultaneous mediators. Applying a 95% confidence interval, the total indirect effect of self-criticism on eating disorder pathology was significantly different from zero suggesting that its influence occurred through the proposed set of mediators. Specific indirect effects revealed that shame was the only mediator to contribute significantly to the model. CONCLUSIONS: Results support the theory that among eating disorder patients, higher self-criticism is associated with elevated eating disorder pathology through feelings of shame. Interventions that target the shame of self-critical patients might therefore facilitate their recovery.

Self-compassion and fear of self-compassion interact to predict response to eating disorders treatment: a preliminary investigation.

Gilbert (2005) proposed that the capacity for self-compassion is integral to overcoming shame and psychopathology. We tested this model among 74 individuals with an eating disorder admitted to specialized treatment. Participants completed measures assessing self-compassion, fear of self-compassion, shame, and eating disorder symptoms at admission and every 3 weeks during treatment. At baseline, lower self-compassion and higher fear of self-compassion were associated with more shame and eating disorder pathology. Multilevel modeling also revealed that patients with combinations of low self-compassion and high fear of self-compassion at baseline had significantly poorer treatment responses, showing no significant change in shame or eating disorder symptoms over 12 weeks. Results highlight a new subset of treatment-resistant eating disorder patients.

The whole is more than the sum of its parts: A qualitative investigation of body-dissatisfied college women's experiences of relational body image.

Research on relational body image suggests that women's body image changes across their important relationships, with women most at risk for maladaptive body image reporting the most extreme changes. To enrich our understanding of relational body image beyond that offered by prior psychologically-based quantitative research, the present study integrated critical-feminist approaches. Eighteen female-identified university students participated in a one-on-one semi-structured interview. Each participant first completed ratings of her body image across seven important relationships, which the interviewer used to create a graph depicting her relational body image. The interviewer shared the graph with the participant to prompt reflection on her subjective experiences of relational body image and asked her a series of questions. Reflexive thematic analysis, informed by a critical-realist framework, was used to identify themes. One overarching theme, "The Whole Is More than The Sum of Its Parts," demonstrated how relational body image may be understood as a unique configuration of interconnected factors within a specific relationship. Three subthemes then highlighted how interpersonal, idiographic, and systemic factors come together to influence subjective experiences of relational body image. The present results suggest that personalized treatment targets within specific relationships may be a worthwhile focus for future body image interventions.