The development of the Compassion Focused Therapy Therapist Competence Rating Scale.

OBJECTIVES: Compassion-focused therapy (CFT) has shown promise as a treatment for a number of clinical presentations; however, existing studies have not adequately addressed issues of treatment fidelity. The aims of the present study were to identify initial candidate items that may be included in a CFT therapist competence rating scale and to develop the behavioural indicators to anchor these items. DESIGN: The Delphi method was used to develop and operationalize the competencies required for inclusion in a CFT therapist competence rating scale over five rounds. METHODS: Face-to-face meetings with two CFT experts were conducted in rounds one, two, and five, and these were used to define and operationalize the competencies. Nine other CFT experts were invited to complete online surveys in rounds two and four. An 80% consensus level was applied to the online surveys. RESULTS: The resulting Compassion Focused Therapy Therapist Competence Rating Scale (CFT-TCRS) consisted of 23 competencies which were separated into 14 'CFT unique competencies' and nine 'Microskills'. There was high agreement about the included 'CFT unique competencies' and 'Microskills'; however, there were some differences in opinion about the specific content of some items. CONCLUSIONS: This is the first study that has attempted to reach consensus regarding the competencies and behavioural anchors for a CFT therapist competence rating scale. The next stage of development for the CFT-TCRS is to establish whether the scale can be reliably and validly used to evaluate CFT practice. PRACTITIONER POINTS: The Compassion Focused Therapy Therapist Competence Rating Scale (CFT-TCRS) is the first scale to operationalize the unique and generic competencies required to deliver compassion-focused therapy (CFT). The CFT-TCRS can be used as a learning guide for delivering CFT training and with further development could be used to assess therapist competence for CFT training courses, clinical practice, and treatment fidelity in research trials.

Muss' Rewind treatment for trauma: description and multi-site pilot study.

BACKGROUND: Rewind is a brief trauma-focussed imaginal exposure treatment for posttraumatic stress disorder (PTSD), however evidence for this treatment is limited. AIM: The aim of this paper was to provide preliminary evidence of its efficacy in the treatment of PTSD symptoms. METHOD: A practice-based pre-post treatment design with an intention-to-treat analysis was used. Sixty three people were treated with Rewind in three separate services. Participants were assessed using the Impact of Events Scale (IES) prior to treatment and were re-assessed at a two-week follow-up. All participants who scored above 25 on the IES were included and there were no other exclusion criteria. RESULTS: There was an overall data capture rate of 95%. After treatment, 55 (87%) participants were below the IES clinical cut-off and, other than three participants with missing data, all participants showed reliable improvement using the IES Reliable Change Index. CONCLUSION: These preliminary findings suggest that Muss' Rewind may offer a useful treatment for PTSD symptoms. Rewind may be cost-effective, given the number of sessions that were required and the relative effectiveness of newly trained therapists in delivering the therapy. Despite methodological limitations, these results suggest that a randomised controlled trial is warranted.

Therapist competencies necessary for the delivery of compassion-focused therapy: A Delphi study.

OBJECTIVES: Compassion-focused therapy (CFT) has shown promising results for a range of clinical presentations. This study explored the therapeutic competencies required to deliver CFT and organized these into a coherent framework. DESIGN: The Delphi method was used to explore and refine competencies for delivering CFT in three rounds of data collection. METHODS: The first round involved interviews with 12 experts in CFT. Data were analysed using template analysis to generate a draft competency framework. The main competencies were used to create a survey for rounds two and three involving CFT experts and practitioners. Data collected from the surveys were used to refine the competencies. RESULTS: The CFT competency framework (CFT-CF) that was produced comprised 25 main competencies within six key areas of competence. The areas were as follows: competencies in creating safeness, meta-skills, non-phase-specific skills, phase-specific skills, knowledge and understanding and use of supervision. The main competencies included several subcompetencies specifying knowledge, skills and attributes needed to demonstrate the main competence. Overall, there was consensus on 14 competencies and 20 competencies exceeded an 80% agreement level. CONCLUSIONS: Some of the CFT competencies overlapped with existing therapies, whilst others were specific to CFT. The CFT-CF provides useful guidance for clinicians, supervisors and training programmes. Further research could develop the CFT-CF into a therapist rating scale in order to measure the outcome of training and to assess treatment fidelity in clinical trials. PRACTITIONER POINTS: The compassion-focused therapy competency framework (CFT-CF) identifies therapeutic competencies that overlap with existing treatments as well as those specific to compassion-focused therapy (CFT). The CFT-CF builds guidance for the competencies required to deliver CFT in a range of clinical settings. The CFT-CF provides guidance for those training CFT therapists. The CFT-CF could be used as a basis to develop a therapist rating scale.

The development and application of compassion-focused therapy for eating disorders (CFT-E).

OBJECTIVES: This article outlines specific developments in compassion-focused therapy (CFT) for the treatment of patients with an eating disorder. METHODS: The article provides a narrative review based on the existing literature and current practices of CFT for eating disorders (CFT-E). RESULTS: The role of shame, self-criticism, self-directed hostility, and difficulties in generating and experiencing affiliative emotion in patients with an eating disorder is highlighted. The article describes how CFT-E uniquely addresses these issues and discusses the current evidence base for CFT-E. It also provides an outline of recent and potential future developments in CFT-E. CONCLUSIONS: CFT-E offers a promising treatment for adult outpatients who present to specialist eating disorder services with restricting and binge/purging eating disorders. Recent developments include treatment protocols for patients who are low weight and have an eating disorder and for those presenting with obesity.

Eating disorder beliefs and behaviours across eating disorder diagnoses.

OBJECTIVE: To test for differences between diagnostic groups on the severity of eating disorder beliefs and behaviours, evaluate the clinical significance of such differences, and assess the extent to which these beliefs and behaviours may be present at clinically significant levels across eating disorder diagnoses. METHOD: 136 adult women outpatients (aged 18-65, with a BMI over 15) were diagnosed with an eating disorder and completed the Stirling Eating Disorder Scale. RESULTS: The expected pattern of statistically significant differences was found between diagnostic groups on anorexic dietary beliefs and behaviours and bulimic dietary beliefs and behaviours. A high percentage of participants in each diagnostic group scored above the clinical cut-off on the eating disorder belief and behaviour measures and a very high percentage of participants in each group reported clinically significant levels of restricting beliefs. CONCLUSIONS: Transdiagnostic or functional analytic approaches to treatment planning may lead to more effective interventions than current, diagnostically-based, care pathways. The high prevalence of restricting beliefs reported suggested that this may need to be a key focus for intervention for the majority of individuals presenting with an eating disorder.

Cognitive Behavioural Therapy for anorexia nervosa: a systematic review.

Evidence for the effectiveness of psychological therapies for anorexia nervosa (AN) is inconsistent. There have been no systematic reviews solely on the effectiveness for Cognitive Behavioural Therapy (CBT) for AN. This review aimed to synthesise and appraise the recent evidence for CBT as a treatment for AN. Using specific search criteria, 16 relevant articles were identified which evaluated CBT alone or as part of a broader randomised/non-randomised trial. Various formats of CBT were utilised in the reviewed papers. Studies were evaluated using established quality criteria. The evidence reviewed suggested that CBT demonstrated effectiveness as a means of improving treatment adherence and minimising dropout amongst patients with AN. While CBT appeared to demonstrate some improvements in key outcomes (body mass index, eating-disorder symptoms, broader psychopathology), it was not consistently superior to other treatments (including dietary counselling, non-specific supportive management, interpersonal therapy, behavioural family therapy). Numerous methodological limitations apply to the available evidence. Further research and ongoing review is needed to evaluate the settings, patient groups and formats in which CBT may be effective as a treatment for AN.

Service attachment: the relative contributions of ward climate perceptions and attachment anxiety and avoidance in male inpatients with psychosis.

BACKGROUND: It has been suggested that mental health services can help meet the attachment needs of inpatients and improve patient outcomes through the provision of a 'secure base'; however, what defines the latter is unclear. Perception of ward climate might be a useful indicator. AIM: The aim of this study was to examine whether inpatient perceptions of the ward climate, which is partly under the control of the service, or inpatients' own personal levels of attachment anxiety and avoidance are more associated with their attachment to their service. METHOD: Seventy-six men diagnosed with a psychotic illness, who were residents in one of four regional medium-security units in England, completed questionnaire measures of service attachment, personal attachment style and ward climate. RESULTS: Ward climate was more strongly associated with service attachment than personal levels of attachment anxiety and avoidance. The most important aspect of ward climate for service attachment was the depth and influence of staff support for the inpatients. CONCLUSIONS: Although patient characteristics are important influences on development of service attachment, ward climate is also important. The latter may be easily and reliably monitored with a brief questionnaire. Strategies to enhance and maintain its positive components are likely to be important for progress with forensic hospital inpatients who have a psychotic illness.

A systematic review of the literature on family functioning across all eating disorder diagnoses in comparison to control families.

The objectives of this review were to systematically identify and evaluate quantitative research comparing family functioning (a) in eating disorder families with control families, (b) in families with different eating disorder diagnoses (c) perceptions of different family members and (d) the relationship between family functioning and recovery. This adds to the findings of previous reviews of family functioning by including data from control families, the range of diagnoses, and focusing on recovery. Findings were considered in relation to models of family functioning. Using specific search criteria, 17 research papers were identified and evaluated. Findings indicated that eating disorder families reported worse family functioning than control families but there was little evidence for a typical pattern of family dysfunction. A consistent pattern of family dysfunction for different diagnoses was not suggested but patients consistently rated their family as more dysfunctional than one or both of their parents. With respect to outcome and recovery, those with more positive perceptions of family functioning generally had more positive outcomes, irrespective of severity of eating disorder. Conclusions were limited by inconsistent findings and methodological issues. Further research is needed into the relationship between family functioning and outcome and the assessment of family functioning beyond self-report.

Shame, pride and eating disorders.

This paper explores shame and shame-based responses in eating disorders. Research linking shame with eating disorders and the possible role of shame and pride in the onset and maintenance of eating disorders is reviewed. The experience of shame is likely to be complex, dynamic and variable. However, the key to identifying shame is often via the various coping strategies adopted, which in turn may form part of a maintenance cycle for eating disorder beliefs and behaviours. An outline model of shame and pride cycles in the maintenance of eating disorders is presented with clinical implications.

Shame in women with a history of eating disorders.

OBJECTIVE: Several studies have investigated shame in eating disorders but most have used non-clinical samples examined only one type of eating disorder or included only a limited range of shame measures. The current study explored shame from multiple perspectives in women who report a range of eating disorder diagnoses and who are at different stages of illness and recovery. METHOD: In a postal questionnaire study, 224 women with a history of an eating disorder completed measures of anorexic and bulimic symptoms, depression and shame. RESULTS: After controlling for levels of depression, shame was associated with eating disorder symptoms. Specifically, shame as a measure of 'perceived involuntary subordination' (external shame) was uniquely associated with severity of anorexia nervosa symptoms, while shame as a measure of 'feelings' (internal shame) was uniquely associated with severity of bulimia nervosa symptoms. DISCUSSION: Different types of shame are related to different eating disorder symptoms and this may have implications for the aetiology and presentation of these disorders. These affective states may need to be addressed explicitly in therapy.

Social comparison and submissive behaviour in eating disorder patients.

Animal analogues of anorexia nervosa suggest that submissive behaviour and social defeat may be implicated in the onset of wasting diseases. Data from human sufferers of anorexia nervosa and bulimia nervosa are also consistent with the presence of submissive behaviours and perceived low social rank (e.g. low self-esteem, helplessness, and feelings of shame). A total of 101 patients with eating disorders completed the Submissive Behaviour Scale and the Social Comparison Rating Scale, and their responses were compared with 101 age- and sex-matched student controls. Patients with eating disorders reported significantly higher levels of submissive behaviour and a more unfavourable social comparison than did student controls. Furthermore, levels of submissive behaviour and unfavourable social comparison were significantly related to severity of eating disorder symptoms, even after taking account of depressive symptoms and other psychopathology. These preliminary results suggest that ranking theory may have some application to eating disorders. Further research is required to determine whether rank plays a specific role in eating disorders (beyond the increased rates of depression which also occur in eating disorders) and, if so, what is its precise role.