self-compassion and treatments for anxiety disorders: a ...€¦ · preliminary evidence suggests...
TRANSCRIPT
Running Head: SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375 Student Number: 500358375
1
Self-Compassion and Treatments for Anxiety Disorders:
A Systematic Review
Anders Nielsen
Student Number: 500358375
December 2018
Presented for MSc in Mindfulness-Based Approaches
School of Psychology, Bangor University
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
2
Acknowledgements
I would like to thank my supervisor Judith Roberts for her assistance and guidance in
developing and completing this project: your encouragement and support pulled me through.
My gratitude also goes to Andrew, Sally and Alex in Portugal, and Mike in
Amsterdam: they helped me change course and continue to inspire. For the same reasons I
want to thank Sally, Tom, Elise and Mark, my tutors at the IACTP in Cashel, Ireland, and the
IACTP-class of 2009. I owe a particular debt of gratitude to Frank, Jenny, Driekske, Heleen,
Cissy, Meino and Tom, my former mentors, colleagues and friends at the Tactus 12-
Stappenbehandeling. They guided my first steps in clinical work, illuminating the role of
compassion in both recovery and addiction treatment long before I became aware of a
theoretical foundation for this.
I would also like to thank to all of my teachers and tutors at Bangor University’s
Centre for Mindfulness Research and Practice, and my fellow-students there. A special word
of thanks goes to the members of the ‘Dharma Dogs’ peer-support group: your wisdom and
friendship proved invaluable these five years.
Finally, I would like to thank my wife Fieke and my daughters Bjørg and Sigrid, who
have been extremely patient, understanding and supportive while I continued to sacrifice
family time in the name of academic pursuits.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
3
Declaration Page
This work has not previously been accepted in substance for any degree and is not being
concurrently submitted in candidature for any degree.
Signed A. Nielsen (candidate)
Date 16/12/2018
STATEMENT 1
This thesis is the result of my own investigations, except where otherwise stated. Where correction
services have been used, the extent and nature of the correction is clearly marked in a footnote(s).
Other sources are acknowledged by footnotes giving explicit references. A bibliography is appended.
A. Nielsen (candidate)
Date 16/12/2018
STATEMENT 2
I hereby give consent for my thesis, if accepted, to be available for photocopying and for inter-library
loan, and for the title and summary to be made available to outside organisations.
A. Nielsen (candidate)
Date 16/12/2018.
Word count: 9859
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
4
Contents
Abstract……………………………………………………………………………………….5
Introduction………………………………………………………………………..…….……6
Method……………………………………………………………………………..………...13
Results…………………………………………….…………………………………….……14
Discussion………………………………………………………………………...……….…28
Conclusions…………………………………………………………………….....…….……30
References………………………………………………………………………...…….……31
Appendices………………………………………………………………………………...…44
APPENDIX A: Tables…………………………………………………….…....44
Table 1: Primary Anxiety Disorders, Clinical Descriptions,
and Lifetime Prevalence………………………………………………..44
Table 2: Summary description of study designs, populations,
interventions and main outcomes……………………………………….45
Table 3: Summary description of disorders, populations, treatment
and (self-)compassion components in treatments under examination….49
APPENDIX B: Third wave intervention for anxiety disorders and
Self-Compassion Scale screening and selection tool…………………………..53
APPENDIX C : CRD informed research study quality assessment tool…..…..55
APPENDIX D : CASP RCT Checklist………………………….……..............56
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
5
Abstract
The interest in therapeutic interventions informed by mindfulness is growing. Self-
compassion is a construct that is associated with psychological well-being. It has been
identified as a potential mechanism of change of these interventions. This thesis is informed
by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
items guidelines and provides an evaluative systematic review of studies of interventions for
anxiety disorders. A systematic search of two databases was conducted for studies that used
the Self-Compassion Scale (SCS) as an outcome measure. This search yielded 115 papers and
nine studies were eligible for inclusion. Study quality was assessed by means of the Critical
Appraisals Skills Programme (CASP) Randomised Controlled Trial Checklist, and a tool
based on the Centre for Reviews and Dissemination (CRD) guidance document. It is
concluded there is preliminary evidence that interventions based on, or informed by
mindfulness may reduce symptom severity and increase self-compassion in patients with post-
traumatic stress disorder, social anxiety disorder, or related symptomatology. Furthermore,
preliminary evidence suggests that integrating self-compassion practices in treatments for
these patients may be feasible and acceptable across a wide range of populations, treatment
settings, and delivery methods. It is noted that adverse events or effects associated with self-
compassion practices were reported. A potential use of the SCS as an aid for clinicians
treating patients for substance abuse disorder is suggested. The limited generalisability and
the lack of comparability between the included studies is noted and suggestions for further
research are discussed.
Keywords: self-compassion, anxiety disorders, mindfulness, substance use disorders
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
6
Self-Compassion and Treatments for Anxiety Disorders:
A Systematic Review
Over the last decades a group of interventions for treatment across mental and
personality disorders known as ‘third wave’ psychotherapies has emerged, including
Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, & Wilson, 1999) and
Dialectical Behavioural Therapy (DBT) (Linehan, 1993). Building on the ‘first wave’ of
behaviour therapy, focused on operant and learning and classical conditioning and the ‘second
wave’, which focused on information processing; these psychotherapeutic methods are
supported by an emerging body of research showing their efficacy and effectiveness (Hayes,
2016; Kahl, Winter, & Schweiger, 2012; Öst, 2008). Third wave methods have shown the
potential to be effective with patients groups that were considered ‘difficult’ in the past (Kahl
et al., 2012). Although there is no suggestion of - or evidence for - the superiority of this new
approach, third wave behavioural interventions are considered to be more in line with the
current research on psychological mechanisms than ‘classical’ cognitive therapy and they are
strongly rooted in learning theory. Despite the fact that their diverse nature precludes
categorising them as belonging to one of the traditional approaches in psychotherapy (e.g.
cognitive or behavioural), they share a number of common themes and factors, such as
acceptance, cognitive (de)fusion, dialectics, spirituality, (therapeutic) relationship and
mindfulness (Hayes, 2016; Kahl et al., 2012)
Mindfulness: a Common Framework
A number of these third wave interventions have been informed by mindfulness,
which has generated considerable interest in the fields of psychiatry, psychology and
psychotherapy (Didonna, 2009). These empirically supported interventions train participants
in mindfulness meditation and encourage and support participants in the application of the
skills acquired through this training in everyday life, ameliorating mental health difficulties
and fostering therapeutic change (Baer, 2014). In this context mindfulness can be defined as
“the awareness that emerges through paying attention on purpose, in the present moment, and
non-judgementally to the unfolding of experience moment by moment” (Kabat-Zinn, 2003, p.
143). These interventions can be divided into two categories: those in which mindfulness
meditation is a central element of the curriculum, theoretical underpinning and therapeutic
approach, described as mindfulness-based programmes (MBPs); and those that share parts of
their theoretical foundation with MBPs, often including mindfulness meditation practices
described as mindfulness-informed programs (MIPs) (Crane et al., 2016).
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
7
A common framework for all MBPs is provided by their parent interventions:
Mindfulness-Based Stress Reduction (MBSR) (Kabat-Zinn, 2005) and Mindfulness-Based
Cognitive Therapy for depression (MBCT) (Segal, Williams, & Teasdale, 2013). MBSR
broke new therapeutic ground by integrating practices and theories derived from
“contemplative traditions, science, and the major disciplines of medicine, psychology and
education” (Crane et al., 2016, p. 990). It incorporated these in a protocolled intervention
(Blacker, Meleo-Meyer, Kabat-Zinn, & Santorelli, 2009) which aims to cultivate an attitude
of acceptance and openness to experiences, both internal and external, as they unfold. MBCT
introduced elements from cognitive therapy to the MBSR framework, aiming to acquaint and
familiarise participants with a new manner of relating to feelings, thoughts and physical
sensations known to precipitate depressive relapse (Segal et al., 2013). MBPs do not teach
participants to challenge mental and physical events, instead they aim bring about a
fundamental shift in perspective towards these events, described as “reperceiving” by Shapiro,
Carlson, Astin and Freedman (2006, p. 377). Thereby enabling participants to turn towards
their experiences in an open, curious, kind and non-judgemental manner, including those held
to be negative or difficult (Kuyken & Evans, 2014). The cultivation of self-compassion is
instrumental in developing this orientation (Feldman & Kuyken, 2011; Segal et al., 2013).
Mindfulness-based treatment can be used across a wide range of clinical areas, clinical
settings and populations (Didonna, 2009). These interventions have some important boons
compared to more established treatments: applicability across a wide range of disorders, a
cost-effective delivery format (8-12 weekly group sessions), a general absence of unwanted
side effects and a reduction of the stigma by participants that is attached to receiving mental
health treatment (Baer, 2014). Nevertheless, the researchers who developed MBCT argue that
mindfulness cannot be applied as a generic treatment approach for psychopathology and
found it can be unhelpful to some patients struggling with depression (Segal et al., 2013).
Walsh and Roche (1979) reported patients with a history of schizophrenia having psychotic
episodes after engaging in intense meditation. Furthermore, Lindahl et al. (2017) argued that
the randomised control design typically used in trials to assess efficacy and effectiveness
provides reliable and accurate information on the positive meditation-related effects of
treatment, but may not inform as adequately on adverse effects of meditation for a variety of
reasons. These researchers found in their mixed methods study of contemplative experience
that some meditation-related experiences are “typically underreported, particularly
experiences that are described as challenging, difficult, distressing, functionally impairing,
and/or requiring additional support” (Lindahl et al., 2017, p. 1). Kocovski, Segal and
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
8
Battista’s (2009) advocated a ‘problem formulation’ approach for developing and using
mindfulness-based approaches in psychotherapy. They proposed that mindfulness may be
most efficacious in an intervention tailored to a specific complaint, integrated with evidence-
based interventions in a theoretically consistent manner; guided by an understanding of the
mechanisms of change for the intervention, which is translated into a problem formulation
shared with participants, elucidating how mindfulness may facilitate therapeutic change.
Mindfulness and Substance abuse Treatment
The problematic use of alcohol and illicit drugs is a major public health concern: the
global prevalence of alcohol use disorders (defined as the aggregate of harmful use and
dependence) was 4.1% in 2010 (World Health Organization, 2014). In 2012 globally 3.3
million deaths could be attributed to the harmful use of alcohol, representing 5.9% of the total
number. In that year alcohol consumption takes the onus for 5.1% of the worldwide burden of
disease and injury. Additionally 0.6% of the global adult population, that is 29.5 million
people, engage in problematic drug use (defined as injecting, using illegal drugs daily or
diagnosed with drug use disorders on clinical criteria) (United Nations Office on Drugs and
Crime, 2017). Behavioural therapies are the most common forms of addiction treatment
(National Institute on Drug Abuse, 2018). Effective treatment varies, based on the nature of
the substance being abused and characteristics of the patient, taking associated medical,
psychological and socio-economic problems and characteristics into account. The earlier
treatment is offered in the addiction process, the likelier it is to result in a positive outcome, as
is the case with other chronic diseases. The relapse rate of 40-60% of patients is also on a par
with other chronic diseases (e.g. Type 1 diabetes and hypertension). A range of tailored
treatment program and follow-up options is available, including both medical and mental
health services.
A recent systematic review and meta-analysis by Li, Howard, Garland, McGovern and
Lazar (2017) found that mindfulness treatment is a promising intervention for substance
misuse, but that more research was needed into the effectiveness across treatment settings and
patient populations, as well as further research into the potential mechanisms of change.
Currently two empirically supported, manualised mindfulness-based interventions for
substance abuse and relapse prevention exist. Mindfulness-Based Relapse Prevention
(MBRP) (Bowen, Chawla, & Marlatt, 2011) is a MBP designed as an after-care program
following treatment for addictive behaviours. It integrates the theory and practices rooted in
cognitive-behaviour therapy (CBT) from Relapse Prevention (RP) (Marlatt & Donovan, 2008)
with mindfulness-based techniques in the framework provided by MBCT. Mindfulness-
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
9
Oriented Recovery Enhancement (MORE) (Garland, 2013) is a MIP aimed to support all
individuals wishing to extricate themselves from addiction, intended for delivery across a
variety of treatment settings and populations. It integrates principles and techniques drawn
from CBT, positive psychology and mindfulness training.
Building on the theoretical foundations of RP for alcohol and drug problems
(Witkiewitz & Marlatt, 2009) and MPBs (Baer, 2003; Bishop et al., 2004; Hölzel et al., 2011;
Shapiro et al., 2006), Penberthy et al. (2015) proposed psychological and physiological
mechanisms of action for MBRP. They noted that further research into which participants
responded to MBRP and why, is needed for tailoring the implementation of this intervention.
Witkiewitz et al. (2014) reviewed these foundations and hypothesised mechanisms of change
by which mindfulness training moderates the relapse process, and recommended studying
how these treatments have been adapted for specific settings and populations. They
hypothesised that mindfulness training may directly moderate the relapse process by
“increasing awareness, decreasing automatic non-mindful responding and judgmental
thinking, and increasing kindness and self-compassion” (p. 517). In comparison with the
hypothesised mechanisms of change for MBPs self-compassion stands out, because only
Kuyken et al. (2010) explicitly identify it as a mechanism of change for the parent
interventions of MBRP. In keeping with its roots in Buddhist and Western psychology the
cultivation of compassion is considered central to the potential for healing that MBPs offer
participants. Feldman and Kuyken (2011) have outlined how the cultivation of compassion by
participants is a central element in MBPs, even though it is not explicitly taught in the
curricula of their parent interventions. Segal, Williams and Teasdale (2013) decided not to
include formal compassion or loving-kindness practices in the MBCT curriculum. They
feared that any invitation to practice loving-kindness or compassion meditation might
immediately cause participants to revert to deeply engrained habits, such as considering
themselves to be unlovable, unworthy or imperfect.
Loving-kindness meditation (LKM) (Salzberg, 2011) is a core practice from the
Theravada Buddhist tradition. The Pali term mettā is often translated into English as ‘loving-
kindness’. Mettā is one of the brahmavihāras, the Buddhist virtues referred to as the “Four
Immeasurables” in English (Bodhi, 2005). Cultivating mettā by means of LKM, fostering an
attitude of kindness towards oneself and others, benefits both the individual practitioner and
society as a whole (Koster, 2012). Compassion, karunā in Pali, is another brahmavihāra.
Compassion meditation helps practitioners cope with pain, adversity and suffering in
themselves and in others, and has similar benefits for society as a whole.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
10
Self-compassion: Construct and Practice
Self-compassion is a construct which is significantly associated with mental health and
psychological well-being. It allows both a kinder attitude towards and more understanding of
oneself, and more perspective on personal experience (Neff, 2003b). Neff’s definition of
“self-compassion entails three main components, each of which has a positive and negative
pole that represents compassionate versus uncompassionate behavior: self-kindness versus
self-judgment, a sense of common humanity versus isolation, and mindfulness versus over-
identification.” (Neff, 2016, p. 265). These components are interwoven aspects of one cyclical
development process, interacting and enhancing each other: on a par with intention, attention,
and attitude, the “axioms of mindfulness” hypothesised by Shapiro et al. (2006) to be the
mechanisms of change underlying all MBPs. The Self-Compassion Scale (SCS) (Neff, 2003a;
Neff, 2016) is a validated, theoretically coherent instrument for measuring self-compassion,
based on the aforementioned definition of self-compassion. High levels of self-compassion as
measured by the SCS have been linked to increased psychological wellbeing and
ameliorations in mental health (Neff, 2003a; Neff, Rude, & Kirkpatrick, 2007). The six
subscales of the SCS correspond with the poles Neff identified as representing compassionate
versus uncompassionate behaviour. The Self-Compassion Scale-Short Form (SCS-SF) is an
abbreviated, reliable alternative with the same factorial structure (Raes, Pommier, Neff, &
Van Gucht, 2011).
The final two sessions of the MBRP curriculum (Bowen et al., 2011) include loving-
kindness mediation. During these final sessions participants are encouraged to select a number
of practices from the curriculum, and incorporate them in a personal program of mindfulness
practices to be sustained and incorporated into their lives after the final session. Bowen,
Chawla and Marlatt (2011) argue that the attitudes loving-kindness practice cultivates are
central to recovery and healing, given the pervasiveness and palpability of self-criticism and
self-judgement in persons with a history of substance abuse and their frequent difficulties in
forgiving themselves for the impact of this abuse on their lives. Garland (2013) incorporated a
combined loving-kindness and compassion meditation in MORE for similar reasons; adding
that the experience of the positive emotions this practice generates may replenish some of the
endogenous neurochemicals involved in self-regulation and adaption to stress. These
neurochemicals may be depleted by chronic substance abuse.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
11
Substance Abuse and Anxiety Disorders
An investigation of patterns of use of mental healthcare and treatment (Harris &
Edlund, 2005) found that half of the respondents who met the criteria for substance abuse
disorders (SUD) at some point in their lifetime, also met the criteria for a mental disorder at
one point in their life, and vice versa: mental and substance use disorders co-occur at a high
rate. Thirty to sixty percent of people with SUD have one or more co-occurring mental
disorders, which should also be addressed in effective treatment (Moos, 2009). Several co-
occurring disorders are exceedingly common in patients presenting themselves for addiction
treatment: mood disorders (40.5%), anxiety disorders (26.4%), post-traumatic stress disorder
(25%), severe mental illness (17.3%), anti-social personality disorder (18.3%) and borderline
personality disorder (17.4%) (McGovern, Xie, Segal, Siembab, & Drake, 2006). Practice
patterns for these patients vary widely (Moos, 2009). Integrated treatment models combining
care for co-morbid disorders seem to be most effective, but little is known about best practices
and critical components of dual-diagnosis treatment programs.
Anxiety disorders are the most prevalent psychiatric problems in the adult population
(Kessler et al., 2005). An overview of the six primary anxiety disorders, their clinical
description and their lifetime prevalence appears in Appendix A, Table 1. The fight or flight
response (Cannon, 1929) is a normal physical reaction to the threat of danger, later the
“freeze” response was added in models of the key behaviours that occur when humans face a
real or perceived threat (Schmidt, Richey, Zvolensky, & Maner, 2007). The fight, flight or
freeze response triggers a wide range of physical, cognitive and behavioural reactions in
preparation of responding to the threat; including the secretion of stress hormones, an increase
of heartbeat, breathing rates and muscle tension, and the concurrent the experiencing of fear
in the brain: a narrowing of the focus of attention, the occurrence of negative or even
catastrophic thoughts, difficulty concentrating, and pacing or fidgeting (Daley & Moss, 2003;
Greeson & Brantley, 2009). Anxiety disorders can occur if the normal and adaptive responses
to a threatening situation are triggered in inappropriate situations, persist well after the threat
has passed, or lead to the restriction of activities through avoidant behaviour.
A belief in the anxiolytic effect of substance use is deeply engrained in our culture. In
ancient times Hippocrates (1886, p. 269), the father of Western medicine, advocated drinking
wine mixed with an equal measure of water as a remedy against “anxiety and terrors”. In his
tension reduction hypothesis, Conger (1956) proposed that alcohol is used to reduce tension
and anxiety, and that its consumption may be continued to avoid these: a reinforcing process
of self-medication. Modified versions of this theory are still relevant to our understanding of
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
12
alcoholism (Young, Oei, & Knight, 2010). Later research found the relationship between
anxiety disorders and substance abuse to be close, varied and complex. Some may appear to
precede substance dependency, indicating self-medication as a possible causal effect; others
may appear to be the result of the worsening of anxiety symptoms into a pathological
condition as a result of chronic substance abuse (Daley & Moss, 2003). For instance,
agoraphobia and social phobia often precede problematic alcohol use, possibly indicating
attempts at self-medication. Whereas panic and generalised anxiety disorder often seem to
follow the onset of alcohol problems (Kushner, Sher, & Beitman, 1990). Kusher et al. (1990)
argued that the negative consequences of chronic alcohol abuse may themselves be
anxiogenic: anxiety symptoms can manifest as a result of SUD (SAMSHA, 2005). Fear and
anxiety are also common threads in self-help groups attended by persons recovering from
substance abuse (e.g. Alcoholics Anonymous, 2001; Narcotics Anonymous, 2008).
Furthermore, the prevalence of SUD in the families of people suffering from anxiety disorders
is significantly higher compared to the general population (Daley & Moss, 2003). A variety of
strategies and interventions are used to treat anxiety disorders. Comparable to treatment
strategies designed for SUD, cognitive approaches aim to teach patients to realistically assess
difficult or threatening situations and address flawed thinking. Behavioural approaches are
aimed at specific target behaviours (e.g. phobias), the improvement of social skills and
encourage and the pursuit of alternative, non-triggering activities. Lifestyle strategies aim to
improve dietary and personal habits, and teach the use of breathing, meditation or relaxation
techniques.
The desire to avoid the inner experience of fear is a characteristic of anxiety disorders
(Greeson & Brantley, 2009). The psychobiological nature of the responses triggered in
patients and the models for maladaptive cognitive response to their inner experience of fear,
shares much common ground with the those described in the theoretical foundation for MBPs.
Self-compassion: Instrument and Indicator
The emerging body of research on the manualised, evidence-based mindfulness
treatments for SUD and anxiety disorders identify self-compassion as an important construct
and potential mechanism of change for these interventions. Van Dam, Shepard Forsyth and
Earleywine (2010, p. 123) described self-compassion as “a robust and important predicator of
psychological health that may be an important component of MBIs [Mindfulness-based
Interventions] for anxiety and depression”. However, further research is needed in order to
effectively adapt treatment across populations and treatment settings (Li et al., 2017). For fear
of triggering vulnerabilities also common in patients with anxiety disorders the developers of
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
13
MBCT made an informed decision not to include self-compassion practices in their
curriculum. On the other hand loving-kindness and compassion meditation practices are
included in the curricula for the manualised, evidence-based treatments for SUD that
incorporate mindfulness. Both Marlatt, Chawla and Bowen (2011) and Garland (2013)
describe how observing and experiencing the initial difficulties patients encounter when first
introduced to these practices (which incorporate explicit instructions for cultivating self-
compassion), are an important and integral part of the curriculum.
Given the high prevalence of patients with co-existing substance abuse and anxiety
disorders and the fact that many patients with SUD present anxiety symptoms,
the present work aims to inform the development of adaptations of MBPs and MIPs for SUDs
by examining the relationship between self-compassion and treatment outcomes in trials of
interventions for anxiety disorders.
Method
Literature search
In March 2018 the author searched the electronic databases ProQuest and Web of
Science for articles published up to December 2017. The search aimed to identify studies of
interventions for anxiety disorders which use the Self-Compassion Scale as an instrument.
The search string employed was “anxiety disorder* AND Self-Compassion Scale AND
mindfulness”, in combination with filters for peer-reviewed articles, published in English.
Searching ProQuest the databases selected were: Periodicals Archive Online, PILOTS:
Published International Literature On Traumatic Stress, ProQuest Historical Newspapers:
The Guardian and The Observer, ProQuest Social Sciences Premium Collection, PsychINFO
and Social Science Premium Collection; 109 records were retrieved and documented. A
search of the Web of Science database employing the same search string resulted in 17
records, which were retrieved and documented. In addition the author hand searched the
research publications (Neff, 2018) listed on the website of Kristin Neff, who developed the
SCS, using the same criteria in March 2018; this yielded a further 26 records. Finally, Dr.
Neff was approached via e-mail, requesting information regarding unpublished literature. This
did not yield any additional records. The author read titles and abstracts for all records
documented in this manner and retrieved the entire article if there was an indication of an
experimental study examining an intervention for an anxiety disorder that used the Self-
Compassion Scale (SCS) as an instrument.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
14
Selection of studies
Studies were included in this review if they (a) had adult participants with a clinical diagnosis
of an anxiety disorder or presenting related symptoms; (b) examined an intervention for
anxiety disorders which incorporates the exploration of inner experience; and (c) were
published in peer-reviewed journals in English. Studies were excluded if they (a) did not asses
self-compassion using the SCS as an instrument; (b) included children and minors as
participants; (c) were systematic reviews or meta-analyses. Comparators were not included as
a criterion for selection. The primary outcome measures examined in the present review are
variations in (a) anxiety symptom severity and (b) self-compassion levels at post-treatment
and follow-up assessments, and (c) associations between these two outcomes. Secondary
outcome measures examined are (a) feasibility of the intervention and (b) participant
acceptability of the intervention.
The author read and assessed all retrieved studies for inclusion, using the screening
tool included as Appendix B. A flow chart illustrating the screening and selection process for
this review appears in Figure 1.
Data extraction and synthesis
The risk of bias of all included studies was additionally assessed with a tool based on
the Centre for Reviews and Dissemination (CRD) guidance document for undertaking
systematic reviews (2009) and the results tabulated. This tool is included as Appendix C. Data
were extracted from the selected studies with the Critical Appraisals Skills Programme
(CASP) Randomised Controlled Trial Checklist (2018), which is included as Appendix D.
The pre-specified outcomes were tabulated and discussed in a narrative synthesis. Due to the
heterogeneous nature of the data statistical synthesis was considered inappropriate, precluding
meta-analysis.
Results
Characteristics of the included studied
Nine studies met the inclusion criteria for the current review. Their designs, populations,
interventions and main outcomes are summarised in Appendix A, Table 2. Five of the
included studies were designed as a Randomised Controlled Trial (RCT), which is considered
to provide the most reliable evidence when examining the impact of interventions (Higgins &
Green, 2011). Four studies were not designed as RTCs. Although not on a par with RCTs in
the hierarchy of evidence, the within-subject nature of the data from the three uncontrolled
non-RCT studies provides strong evidence when examining the relationships and associations
between dependent variables.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
15
Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-
Analyses) flow diagram (Moher, Liberati, Tetzlaff, & Altman, 2009). Studies
examining interventions for anxiety disorders incorporating the exploration of
internal experience.
Five studies examined interventions for Post-Traumatic Stress Disorder (PTSD) or
trauma-related symptoms and four investigated treatment aimed at SA Disorder (SAD) or
related symptomatology. Sample sizes ranged from 6 to 65. The characteristics of the
interventions under examination varied widely, as did their methods of delivery. Five of the
interventions incorporated either explicit (self-)compassion practices, exercises or techniques,
or LKM. Two of these were adaptations of exposure, a key element in most CBT treatments
for anxiety disorders (Rodebaugh, Holaway, & Heimberg, 2004). Treatment was delivered
individually in four studies, in a group format in another four studies, and one study examined
an intervention delivered by means of a workbook. A summary description of targeted
disorders, populations, treatments and (self-) compassion components incorporated in the
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
16
treatments under examination for the included studies is provided in Appendix A, Table 3.
This review will first present a brief summary of the included studies ordered by
design, subsequently summarising treatment delivery and outcomes for these studies arranged
by the disorder they address. The potential for bias of all included studies assessed by means
of the CRD tool appears in Appendix A, Table 4.
Summary of RCT designs
Four of the five included RCTs randomised participants directly to active control
groups, one to a waitlist control group. All researchers reported on ethics and informed
consent procedures, and formulated clear inclusion criteria regarding the anxiety disorder or
related symptomatology and the intervention under examination. Jazaieri, Goldin, Werner,
Ziv and Gross (2012) and Koszycki et al. (2016) recruited their clinical samples through
referrals from mental health care providers, and through self-referrals via advertising at these
facilities and on-line. Hoffart, Øktedalen and Langkaas’ (2015) experiment was the only RCT
situated outside the USA. This Norwegian study exclusively recruited participants who had
been referred to an in-patient treatment program for PTSD. Consequently it was the only RCT
to preclude self-selection bias, as the others all included participants who self-referred.
The RCTs that examined clinical samples all reported on inclusion or exclusion
criteria with regards to ongoing psychotherapy, psychotropic medication and co-morbid
psychopathology or related symptoms. Hoffart et al. (2015) and Koszycki et al. (2016)
formulated criteria around suicide risk. Jazaieri et al. (2012) and Hoffart et al. (2015)
excluded those engaged in concomitant psychotherapeutic interventions, and participants
using psychotropic medication. Koszycki et al. (2016) included participants with stable
medication types and doses, provided these did not change after randomisation. The studies
examining MBPs excluded participants with ongoing meditation practices. Additionally
Koszicky et al. (2016) excluded those with a regular yoga practice, and Jazaieri et al. (2012)
excluded participants who had previously completed a MBSR course. Hoffart et al. (2015)
and Koszycki et al. (2016) both reported on blinding and concealment during the allocation of
participants across treatment groups. They also specified the randomisation technique
employed, as did Jazaieri et al. (2012). Held and Owens (2015) and Valdez and Lily (2016)
provided no information about their randomisation process, impeding assessment of potential
confounding through allocation and performance bias.
Two RCTs examined specific target populations, thereby limiting the generalisability
of their findings. Valdez and Lily (2016) recruited female participants from the Psychology
Department of a university and local community who had been exposed to trauma. They
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
17
advertised locally and contacted participants in earlier studies conducted at that university.
They excluded those whose trauma exposure had occurred before they were 16 years old,
those whose trauma had occurred within three months of recruitment, and those for whom
participation might have resulted in additional stress or encumbered study results. Held and
Owens (2015) recruited their participants from a transitional housing facility for homeless
veterans, with an intermediate reading level as the only criterion for eligibility. Participants in
this study continued to receive their regular treatment at an out-patient clinic for veterans and
at their housing facility. This included psychotherapy, pharmacotherapy, and attending
support and self-help groups.
Taken together the eligibility criteria denote considered efforts in four RCTs to reduce
confounding dependent variables and optimise internal and external validity. Held and
Owens’ use of a single inclusion requirement appears less rigorous by comparison. On the
other hand their target population is much more difficult to access for both researchers and
mental health care providers (van den Bree, Bonner, Taylor, & Shelton, 2009). Another
indication of the methodological strength of the included studies is how they seek to minimise
the risk of attrition bias and missing data affecting the validity of their results. Three RCTs
used intent-to-treat (ITT) analysis (Fisher et al., 1990) (see Appendix A, Table 4). In Held and
Owens’ study (N = 47) 43% of participants dropped out during the treatment period, the
reasons were not reported. Their analysis used the sample (n= 27) that completed all
assessments; compared to ITT-analysis this approach is considered to be less effective in
eliminating bias (Higgins & Green, 2011). On this aspect of quality assessment Valdez and
Lily’s RCT stands out, because they provided neither a flowchart of their participants, nor
equivalent data. Thereby precluding assessment of the risk of attrition bias and missing data
affecting the internal and external validity of their results. A further indicator of
methodological rigour is the reporting of observed means, standard deviations and other
descriptive statistics for continuous variables. Jazaieri et al. (2012), Koszycki et al. (2016),
and Held and Owens (2015) provided these data. Hoffart et al. (2015) and Valdez and Lily
(2016) did not.
Summary of non-RCTs designs
Kearney et al. (2013) were the only researchers in the non-RCT category to examine a
clinical sample. This consisted of veterans with current PTSD receiving treatment at an urban
veterans hospital in the USA. Some of the participants were referred by health-care providers
and others referred themselves. These researchers did not report on their method of
recruitment. Boersma, Håkanson, Salomonsson and Johansson (2015) recruited university
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
18
students experiencing social anxiety (SA) at a Swedish university, advertising both on campus
and on-line. In Norway, Hjeltnes et al. (2017) recruited young adults presenting problems
with SA or SAD via referrals from a university mental healthcare centre and self-referral.
They advertised in the same manner as the Swedish researchers, and pre-screened participants
by telephone. They formulated exclusion criteria around co-morbid serious mental disorders,
suicidality, and substance abuse or SUD. Thereby reducing the threat of selection bias
affecting the internal validity of their findings. Hjeltnes et al. (2017) excluded persons with a
history of severe trauma, and Kearney et al. (2013) those with a history of psychotic disorder.
Boersma et al. (2015) were the only researchers in this category to exclude participants
engaged in concomitant psychotherapy, or recently initiated pharmacotherapy. All of the non-
RCT studies reported on the methods of statistical analysis they employed to assess outcomes,
clinical significance, correlations between outcomes and compare treatment outcomes.
Hjeltnes et al.’s (2017) was the only study to use ITT analysis in this category, strengthening
the generalisability of their findings. Boersma et al. (2015) did not report on either ethics
approval or consent, reported on ethics approval only. Hjeltnes et al. (2017) and Kearney et al.
(2013) reported on both.
Beaumont, Galpin and Jenkins’ (2012) study design stands out in the non-RCT
category, because it included an active control group and randomisation of participants across
treatments. They recruited participants referred by agencies in the UK for CBT after a trauma-
related incident. This comparative outcome study did not report on participant selection,
screening or inclusion and exclusion criteria, or consent, although it did report on ethics
approval. The participants were randomised between two treatment conditions, stratified by
the type of trauma experienced. This study was categorised as a non-RCT, because it
examined a “non-random purposive sample” (p. 34) and did not provide information on their
method of randomisation, nor on the inclusion and exclusion criteria.
Outcomes for studies examining SAD
Boersma et al. (2015) used a replicated single case design to examine the effects of
Compassion Focussed Therapy (CFT) (Gilbert, 2010) in reducing shame, self-criticism and
SA and increasing SC; additionally reporting on both treatment satisfaction and whether
participants experienced treatment helped them cope with SA and increase SC. CFT is an
approach within CBT that “is rooted in an evolutionary, neuro- and psychological science
model” (p. 9), integrating traditional Buddhist concepts and practices around compassion. The
participants (N = 6) were university students experiencing de facto life-long problems around
SA and shyness. Treatment consisted of an adaptation of CFT as presented by Henderson &
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
19
Gilbert (2011), integrating elements from other self-help formats inspired by Gilbert (2010).
It was manualised and delivered in eight weekly, one hour sessions by psychology students
finalising their clinical training. These were supervised by a psychotherapist, treatment
adherence was not assessed. This study used self-report instruments to measure SA, social
interaction, SC and depression, in addition to a diary to track changes in shame, self-criticism
and SC; and a final treatment evaluation questionnaire. Measurements began with a baseline
period, followed by weekly measurements during treatment and a 2-4 week follow-up period.
Data were analysed using the PEM approach (Ma, 2006), suitable for examining treatment
effect in single subject-designs, and a Reliable Change Index (RCI) was calculated (Jacobson
& Truax, 1991) for the SCS and SA symptom measures. PEM scores indicated a strong effect
of treatment for five out of six participants on SC; a questionable effect on shame was
reported for half of the participants (three), a strong effect for two participants and a moderate
effect for one. Additionally, a questionable effect of treatment was reported for half of
participants on self-criticism, with a moderate effect reported for two participants and a strong
effect for one. Further analyses indicated reliable change for five out of six participants on
SC. Results for SA symptoms were mixed, with reliable change reported for only two
participants on one of the outcome measures, and for half of the participants on the other. The
participant’s perception of improvement in coping with SA was more positive: half of
participants reported having improved “a lot” and half “somewhat”, four participants reported
being “very satisfied” with treatment and the remaining two were “quite satisfied” (Boersma
et al., 2015, p. 92-4).
The replicated single case design chosen for this study, although appropriate for a pilot
study, limits the generalisability and external validity of its results. On the other hand this
design inherently allows inferences of cause and effect relationships between variables. This
study could have been strengthened by extending the baseline and follow-up measurement
periods, and including non-self-report measures.
Hjeltnes et al. (2017) conducted an open trial of MBSR for young adults (N = 53)
with SAD. Four of the seven authors of this study delivered treatment. All classes were
taught by at least one clinical psychologist with formal training as a MBSR teacher;
supervision and treatment adherence were not reported on. This study used self-report
measures to assess changes in levels of mindfulness, self-esteem and SC one week before the
intervention, mid-treatment, and after the last class of a MBSR program. The drop-out rate for
this study was 15%. ITT analyses yielded effect sizes that were large for SAD symptoms
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
20
(Cohen’s d = 0.80), moderate for global psychological distress (d = 0.61) and self-esteem (d =
0.63), and moderate to large effects for SC (SCS subscales d = 0.79 – 1.16). The largest
effect sizes were reported for over-all SC (d = 1.16), and the self-kindness (d = 1.03) and
common humanity (d = 0.96) subscales. A clear majority of the participants in the ITT sample
within the in the clinical range for SAD symptoms, reported reliable and clinically significant
change (34%), or reliable change (27%) on these symptoms. This study reported a significant
negative association between changes in SAD symptoms and SC (Pearson’s r = -0.46), as
well as a significant positive association between SC and self-esteem (r = 0.64).
While it was well conceived, this study’s non-experimental design limits the potential
for generalisation of its results and inferring causal relationships from them. On the other
hand, the large sample size and use of ITT analysis strengthen the internal validity of its
findings. This study could have been strengthened further by including non-self-report
measures, a long term follow-up measurement, and excluding the authors from treatment
delivery.
Jazaieri et al.’s (2012) RCT also examined the efficacy of MBSR in treating SAD.
They allocated participants (N = 56) diagnosed with SAD across two active treatment groups:
MBSR (n = 31) and AE (n = 25). In choosing AE as the active comparison condition this
study aimed to “match non-specific factors of MBSR, while having the absence of active
ingredients in MBSR” (i.e. meditation practice, group interaction and psycho-education). It
matched the time and effort required for group and individual components, monitoring
practice and whether participants encountered obstacles on a weekly basis by telephone.
Participants in both groups were asked to record both the frequency and duration of their
group and weekly practices. MBSR was taught by instructors with between 10 and 20 years of
experience, their training, supervision or treatment adherence were not reported; no
information was provided about the aerobics instructors. This study only reported on the
outcomes of statistical analyses of treatment completers, as these were equivalent to those for
the ITT-sample. Two groups of non-randomised participants were included in analyses of
clinical significance: Healthy Controls (HC) (n = 48) and untreated participants with SAD
(UT) (n = 29). The UT group consisted of participants in separate RCT with very similar
inclusion and exclusion criteria (Goldin et al., 2012). The researchers assessed clinical and
well-being symptoms with self-report instrument pre-intervention, post-intervention and three
months after the intervention for participants in the active treatment groups, and at two times
16 weeks apart for the UT group; data collection for the HC group was not specified.
Repeated measures analyses found comparable significant changes for the active treatment
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
21
groups compared to the HCs: both treatments were associated with reductions in SA and
depression, and increases in subjective well-being; these changes were maintained at the 3
month follow-up. No significant difference was found between both active groups on either
clinical (χ2: ps > .09) or well-being measures (χ2: ps > .1). Additional analyses compared the
active treatment groups to the UT group: for the MBSR-group they yielded a significant
decrease in symptoms on most clinical measures; and a significant increase on some well-
being measures, but not for SC and self-esteem. Comparing the AE and UT groups, these
analyses found significant decreases in clinical symptoms for SA and improved SC; no
significant changes were reported for the other clinical and well-being measures. The reported
drop-out rates were 16% for the MBSR group and 8% for the AE group. The average
individual practice time reported for both groups was 3.4 hours per week.
The matching of time and effort required from participants across active treatment
groups, combined with its sample size and the inclusion of an untreated group of participants
with SAD, make this the most methodically robust of the included studies. However, the fact
that participants in the UT group were not directly randomised precludes making direct
inferences from the results that compare this group of participants to those allocated to active
treatments. This study could have been strengthened further by including assessment of
treatment adherence, direct randomisation of all participants, and reporting on allocation
concealment and administration blinding.
Koszycky et al. (2016) investigated the initial efficacy and feasibility of Mindfulness-
Based Intervention for SA Disorder (MBI-SAD), assigning the predominantly white female
participants (N = 39) to either active treatment (n = 21) or waitlist control (n = 18). One of the
authors delivered treatment, which incorporates mindful exposure, LKM and self-compassion
meditation. She reported having formal training in delivering MBPs, expertise in treating
patients with SAD and a personal mindfulness practice. Treatment efficacy was assessed
using a combination of clinician-rated measures and self-reported measures; with the former
administered by assessors blind to group allocation. SC was measured with the SCS-SF. The
number of treatment completers was used to assess feasibility. Home practice compliance was
monitored by requesting participants to keep a daily meditation log. The researchers found the
MBI-SAD group demonstrated significantly greater improvement at the end of treatment
compared to the WL group on SA symptom severity, social adjustment and SC. These
treatment gains were maintained at the 3-months follow-up. The increase in SC correlated
negatively with the end of treatment scores for both measures of SA symptoms (r = -0.57 and
r = -0.53) and clinical global impression (r = 0.54). MBI-SAD was found to be both feasible
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
22
and acceptable: 81% of the participants attended 8 or more out of 12 sessions. The researchers
estimated that on average participants spent half an hour per day on formal mediation practice
at home. Session attendance correlated significantly with engagement in formal practice (r =
0.73) and improvements on post-treatment scores for one of the measures of anxiety
symptoms (r = - 0.49), social adjustment (r = -0.60) and SC (r = 0.53). The time participants
engaged in formal mediation practice correlated with post-treatment SC scores (r = 0.56) and
the total number of days participants engaged in mindful exposure correlated with end of
treatment scores on social adjustment (r = -0.54). More than two thirds of participants in the
MB-SAD group (71%) intended to continue to “engage in some form of formal practice” at
the conclusion of treatment. The follow-up assessment revealed a considerable decrease in the
time they engaged in formal meditation practice compared to the 12-week program.
Notwithstanding its lack of an active control arm, this was a rigorously designed RCT
that combined clinician- and self-rated outcome measures. Well-conceived for a preliminary
investigation of treatment efficacy and feasibility, this study adequately addressed nearly all
aspects of quality assessment selected for this review. On the other hand, the size and
representativeness of its sample limit the generalisability of this study’s findings. It could
have been strengthened further by using an active, rather than a WL control group, controlling
for both the Hawthorne effect and being in a supportive group, thereby improving external
validity. Excluding the authors from treatment delivery would have strengthened this study’s
internal validity as well.
Outcomes for studies examining PTSD
Two studies employed non-RCTs designs to examine interventions for PTSD patients
and trauma-victims. Beaumont et al. (2012) assigned participants (N = 32) who had
experienced a traumatic incident across two groups, receiving either 12 individual sessions of
CBT (n = 16), or CBT coupled with Compassionate Mind Training (CMT) (Gilbert & Procter,
2006) (n = 16). One of the authors, a qualified cognitive behavioural psychotherapist,
delivered treatment. Her training in CMT, supervision and treatment adherence were not
reported on. CMT is the therapeutic technique at the core of CFT (Leaviss & Uttley, 2015).
This study used self-report measures of anxiety and depression, subjective-distress, and SC
administered pre- and post-therapy; treatment adherence, completion and compliance were
not reported on. This study used the SCS-SF to measure SC. Analysis of variance of these
data found highly significant post-therapy reductions of avoidant behaviour, intrusive
thoughts, hyper-arousal symptoms and anxiety for both groups, without finding significant
differences between these groups. Post-therapy levels of SC for both groups also displayed a
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
23
highly significant increase, with the combined CBT/CMT reporting significantly higher
overall levels of SC compared to the CBT-only group.
Although its design is appropriate for an initial exploration of the effect of integrating
a new technique into CBT, this study has several limitations in addition to those around
participant selection and randomisation noted earlier. Only the participants in the combined
CBT/CMT group were informed about one of the specific goals of the intervention: to
“develop empathy for themselves and acceptance of their distress” (Beaumont et al., 2012, p.
34). As a consequence the outcome measures on the SCS are vulnerable to confounding
through participant bias, limiting their internal validity. Excluding the authors from treatment
delivery and including non-self-report measures would have further strengthened this study’s
internal validity.
Kearney et al. (2013) conducted an open trial of LKM for veterans with PTSD in the
US. The veterans (N = 42) followed a 12-week LKM course taught by experienced meditation
teachers. Their qualifications, training, supervision and treatment adherence were not reported
on. This meditation course was delivered adjunctive to the usual care at a veteran's hospital.
The study measured life-time traumatic events, PTSD symptoms, depression, SC,
compassionate love and mindfulness skills at a baseline assessment, conclusion of treatment
and three months post-treatment. Statistical analyses included calculating standard mean
differences, RCI calculation, and mediation analyses. Eighty-eight percent of participants
provided data at the post-intervention assessment and 81% at the three months follow-up.
The researchers found LKM to be highly acceptable for veterans, with 74% of participants
attending 9-12 classes and 86% five or more. They reported large effect sizes for SC, both
post treatment (Cohen’s d = 0.80) and at three months follow-up (d = 0.92). Additionally they
found large and medium effect sizes for PTSD symptoms (d = -0.75) post treatment, and at
the three months follow-up (d = -0.89). Regression equations found that changes in SC scores
significantly mediated changes in PTSD symptoms both between baseline and post-
intervention, and baseline and the three months follow-up.
This was a well-designed open pilot study that provides detailed information on mean
scores and effect sizes for its measures and the correlations among these variables. However,
as the intervention was delivered adjunctive to treatment as usual, concurrent therapy may
have confounded the measured treatment effects. Additionally, over half of the participants
had previously participated in a MBSR program. This study could have been strengthened
further by including an active control arm, adding non-self-report measures and excluding
participants who had completed a MBI program.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
24
Three RCTs investigated the role of SC in treatment for participants with PTSD or
victims of intentionally caused trauma. Valdez and Lily (2016) studied the effect that analytic
and experiential processing modes, and the SC components of self-kindness, mindfulness and
common humanity have on the trauma processing outcomes of negative affect, positive affect,
and anxiety. Traditional CBT typically has an analytical focus, whereas third-wave
interventions have an experiential focus. Their study used a combination of self-report and
clinician administered measures of PTSD symptom severity, depression, SC, and positive and
negative affect, partially administered by one of the authors before and after an individual
laboratory session. The researchers took baseline measures of SC, trauma history and PTSD
severity via an online questionnaire a number of days or weeks prior to the laboratory session.
Their exclusively female sample (N = 63) was assigned across two experimental conditions
and a control group (all ns = 21). Participants in the experimental condition groups received
either an experiential processing, or an analytic processing induction, the control group
received neutral instructions. Subsequently all participants were exposed to an identical range
of scenarios. The various modes of processing were induced by a blinded research assistant.
This study did not report on treatment adherence and the training, nor on qualifications and
supervision of the persons involved in the experimental procedure for the study. Correlation
analysis of baseline measurements for the SCS subscales found an association between
greater scores on two components of SC (self-kindness r = −0.40; mindfulness r = −.39) and
less post-traumatic stress symptom severity. At this point greater self-kindness was associated
with less hyperarousal (r = −.43) and less emotional numbing (r = −.50), as was mindfulness
(r = −.36 and r = −.47 respectively). After trauma processing greater self-kindness was
associated with higher positive affectivity (r = .50) and higher anxiety levels (r = .48); and
greater common humanity also correlated with higher anxiety levels (r = .62). This study
reported correlations for individual treatment groups after trauma processing as well, without
providing descriptive statistics. In the analytical processing group it found greater self-
kindness was associated with less negative affectivity; and mindfulness was associated with
less negative affectivity, less anxiety and greater positive affectivity. In the experiential
processing group greater self-kindness was associated with positive affectivity and higher
anxiety levels, and greater common humanity also associated with higher anxiety levels. In
the control group greater mindfulness and self-kindness were associated with less anxiety and
negative affectivity.
This RCT specifically examined the individual impact of a SC-focussed treatment
component and its CBT equivalent, combining three active treatments in a robust design that
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
25
used both clinician- and self-rated measures. However, the generalisability of its findings is
severely limited by selecting an exclusively female sample. This study could have been
strengthened further by assessor blinding, and reporting on and assessing of the randomisation
procedure.
Held and Owens (2015) investigated the effect of a four-week workbook training on
PTSD-symptom severity and trauma-related guilt cognitions in homeless veterans (N = 47).
They allocated participants across two active interventions: SC training (n = 13) incorporating
SC-exercises commonly used in other interventions (e.g. CMT); and stress-inoculation
training (SI) (n = 14), which incorporated exercises common to this type of training (e.g. deep
breathing, progressive relaxation and visualisation). This study only reported outcomes for the
participants that completed all assessments (n =27) of trauma-related guilt, PTSD symptoms
and SC. These were administered pre-, mid- and post-training. Participants were encouraged
to read the workbooks and practice the exercises they contained for a minimum of 5-15
minutes each day, at a meeting that started the self-administered treatment. Both interventions
contained breathing, visualisation and awareness exercises, prompting the researchers to make
some adaptations in order to avoid overlap. The researchers reported a significant increase in
SC (d - 1.033) and decrease in trauma-related guilt (d = 2.792) for both groups between the
pre- and post-intervention assessments; PTSD-severity did not differ significantly.
In addition to examining the efficacy of SC training, this pilot study investigated the
feasibility of a cost-effective means of delivering treatment to a disadvantaged population.
The internal validity of its results were enhanced by a concerted effort to match the time and
effort across both interventions and to avoid overlap between the included exercises.
Nonetheless, it could have been strengthened further by including a WL control group, and
eliminating a confounding factor by excluding participants engaging in concomitant psycho-
and pharmacotherapy.
The Norwegian RCT examined the influence of SC components on within-person
processes of change during CBT, administered in a residential program. Hoffart et al. (2015)
assigned PTSD patients (N = 67) to two groups receiving either a standard (n = 33) or a
modified (n = 34) form of prolonged exposure (PE) (Foa, Hembree, & Rothbaum, 2007),
which incorporates exposure to the traumatic memory through imagination (IE). In the
modified version of PE the imaginal exposure was adapted in order to foster SC by means of
imagery re-scripting (IR) (Stöfsel & Mooren, 2017). Treatment consisted of 10 weekly
individual sessions lasting 90 minutes and was delivered by experienced qualified therapists,
receiving ongoing supervision; treatment integrity was monitored and evaluated. The session
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
26
content for weeks 1, 2 and 10 was the same for both groups. PTSD symptoms and SC were
assessed weekly using self-report measures, and three days before the end of treatment
participants were asked to rate their experience. In their statistical analyses the researchers
disaggregated the within-person and the between-person components of change. Analysis of
the between-person effect of treatment revealed significant changes over the course of
treatment for five of the SCS subscales: self-kindness, mindfulness, self-judgment, isolation
and over-identification, no significant change was reported for common humanity; and there
were no significant differences between treatment groups. Analyses examining the within-
person effects of treatment found a significant association between higher than usual sores on
the SCS subscales of self-kindness, self-judgment, isolation and over-identification and lower
than usual levels of PTSD symptoms, as assessed three days later. Self-judgement was the
only SCS-subscale to show a positive cross-level effect. These analyses revealed no strong
reciprocal effects, i.e. there was no significant association between changes in PTSD
symptoms and subsequent SC levels.
This RCT was well-designed for investigating the potential of SC as an agent of
change in PTSD treatment as it incorporated specific assessment of within-person effects of
treatment. Matching the time and effort involved the both active treatments, treatment fidelity
assessment and supervision enhanced the internal validity of this study’s results. It could have
been strengthened further by using proportionate stratified random sampling, with the type of
trauma participants were exposed to as a variable.
Summary of outcomes
The included trials of interventions for SAD examined two MBPs: MBI-SAD
(Koszycki et al., 2016), which incorporates explicit SC-practices, and MBSR (Hjeltnes et al.,
2017; Jazaieri et al., 2012), which does not. MBSR and MBI-SAD were associated with
significant reductions in SA symptoms when participants were compared to untreated
controls. MBI-SAD was associated with a significant increase in SC. No significant
difference in SC was found between the active treatment groups in the study comparing
MBSR and AE (Jazaieri et al., 2012). Analyses of post therapy outcomes for MBI-SAD
revealed increases in SCS scores correlated negatively with scores of SA symptoms and
clinical global impression; session attendance correlated with engagement in formal practice,
and improvements in scores for SA symptoms, social adjustment and SC. The uncontrolled
trial of MBSR (Hjeltnes et al., 2017) reported a large effect size for SAD symptoms and
moderate to large effect sizes for the SCS-subscales. Correlation analyses of these outcomes
revealed significant positive associations between changes in SC and self-esteem; as well as
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
27
significant negative associations between changes in SA symptoms and both SC and self-
esteem. CFT (a MIP) was effective for three participants, probably effective for one and
effectiveness questionable for the remaining two participants (Boersma et al., 2015). Five
participants showed reliable improvement on SCS-scores, results for SA symptoms were
mixed.
Three studies investigated the effect of different MIPs incorporating self-compassion
practices on PTSD. The study examining LKM (Kearney et al., 2013) found this practice to
be safe and acceptable for veterans with PTSD. It reported large effect sizes for SC and PTSD
symptoms, both post treatment and at the 3 month follow-up; and evidence that enhanced SC
mediated reductions in PTSD symptoms. SC-workbook training (Held & Owens, 2015)
significantly increased levels of SC and reduced levels of trauma-related guilt, but no
significant changes were reported for PTSD symptoms. There were no significant differences
in treatment outcomes compared to participants in the active control group, who were
assigned to stress inoculation training. These findings indicated that a self-administered
workbook may constitute a feasible and acceptable format for delivering SC training to
disadvantaged populations. Comparing CMT coupled with CBT to CBT-only (Beaumont et
al., 2012) resulted in highly significant post-therapy reductions in symptoms of avoidant
behaviour, intrusive thoughts, hyper-arousal and anxiety for both groups, without finding
significant differences between the interventions. A significant increase in SC for both groups
was reported as well, with the CBT/CMT group developing significantly higher overall SCS-
scores.
Two studies focussed on processes of change in PTSD treatment. The first study (Valdez
& Lilly, 2016) found that SC may exert different effects on trauma-related anxiety and
affectivity across analytic and experiential trauma processing modes. In conditions of analytic
processing greater self-kindness correlated with less negative affectivity; mindfulness
correlated with less anxiety and negative affectivity, and greater positive affectivity; and
greater common humanity correlated with more anxiety. In experiential processing conditions
greater self-kindness correlated with more anxiety and positive affectivity; and greater
common humanity correlated with more anxiety. For the control group both greater
mindfulness and self-kindness correlated with greater less anxiety and negative affectivity.
The other study (Hoffart et al., 2015) explored within-person relationships between SC and
PTSD-symptoms, finding no differences in relations between treatment forms. Changes in
self-kindness, self-judgement, isolation and over-identification related to subsequent changes
in PTSD-symptoms. Participants with higher initial self-judgement showed a stronger within-
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
28
person relationship between self-judgement and subsequent PTSD symptoms. Within-person
variations in PTSD symptoms did not predict variations in SC-components.
Discussion
The aim of the present systematic review was to inform the development of
adaptations of MBPs and MIPs for SUDs. This was undertaken by examining treatment
outcomes and their relationship with self-compassion in trials of interventions for anxiety
disorders, and assessments of the feasibility and acceptability of these interventions.
The wide variety of interventions and population samples under examination, and the
methodological limitations of the included studies severely limits the generalisability of their
findings. This lack of comparability between the studies precludes drawing conclusions on the
effect of including explicit SC-practices in interventions, their effect on treatment outcomes,
and variations in effects between interventions aimed at PTSD and those for SAD. Therefore
the findings of the present review do not provide the type of evidence required to inform the
tailoring or adaptation of MBPs and MIPs in keeping with the problem formulation approach
advocated by Kocovski et al. (2009).
Nevertheless, taken as a whole the findings of the included studies included in this
review suggest that MBIs and MIPs may result in reductions in symptom severity and
increases in SC levels in participants with PTSD, SAD or related symptomatology. The
findings of included trials of MBPs and MIPs offer preliminary support for the predictive
utility of the SCS in MBIs for anxiety disorders suggested by Van Dam et al. (2010); as well
as additional support for the associations between increased levels of SC and reduced levels
of psychopathology and psychological health proposed by MacBeth and Gumley (2012) and
Neff, Rude and Kirkpatick (2007) respectively. Several included studies contribute to the
emerging body of mindfulness research by offering preliminary evidence for the feasibility
and acceptability of MBPs and MIPs that incorporate explicit SC-practices. No obvious
benefits were discernible for the inclusion of explicit SC-practices: the salutary effects of
increased SC were also observed in the trials of MBSR, where self-compassion is only
cultivated implicitly. Furthermore, these benefits were also observed in active control groups
that were exposed to therapeutic methods without an experiential component: AE and analytic
processing mode. Importantly, none of the included studies reported adverse events or side-
effects associated with explicit self-compassion practices.
Notwithstanding its limitations, the findings of this review may indicate a potential
utility of the SCS for clinicians working in SUD treatment. The reported correlations between
outcomes on the SCS-subscales and affectivity may have the potential to inform which
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
29
patients might benefit from LKM or compassion meditation, because positive and negative
affect are predicative of treatment outcomes for SUD (Marlatt & Donovan, 2008). The
reported associations between increased self-compassion and the other outcome measures
may be indicative of a similar potential. Processes and constructs such as avoidance, hyper-
arousal, isolation, self-criticism, guilt and shame are all associated with important risk factors
and determinants of relapse in the “Dynamic model of relapse” (Witkiewitz & Marlatt, 2009,
p. 414). Focused on situational dynamics, this model of relapse aims to inform clinicians
seeking to support their patients in identifying and preventing high-risk situations.
Consequently, clinicians utilising this model may find the SCS useful in discerning which
SUD-patients could benefit from the integration of LKM or compassion practice in their
treatment and relapse prevention plans.
Further research investigating of the role of SC in MBPs and MIPs is needed to
elucidate the role and effect of SC in the treatment of ADs and SU. Such research would
benefit from standardisation of the designs and measures used to investigate the efficacy of
MBPs and MIPs. And from clear definitions of the constructs and practices involved in
compassion meditation, mindfulness mediation and LKM as Shonin, Van Gordon, Compare,
Zangeneh and Griffith (2015) have argued. The difference between Gilbert’s definition of
compassion at the root of CFT and CMT (2010) and the one used by Neff (Neff, 2003a;
2003b) underpinning the SCS, indicates these issues around delineation also have a bearing
on the present review. Furthermore, as Curran and Bauer (2011) have pointed out, collecting
longitudinal data would offer advantages with regard to disaggregating between-person and
within-person effects. The reviewed findings reflect the focus on collecting the between
person data in assessing treatment outcomes noted by Hoffart et al. (2015) in one of the
included studies.
The present review has several serious limitations. The first limitation concerns the
literature search and selection of studies. These were conducted by a single reviewer,
introducing the possibility of bias through selection or omission. Limiting this search to two
electronic databases and studies published in English may add location and language biases.
Second, quality assessment and data extraction were also undertaken solely by the author,
which constitutes a vulnerability for assessment bias and errors. Finally, this review evaluates
the acceptability of therapeutic interventions examining only quantitative data, where
qualitative data have the potential to provide additional and detailed information about how
participants experience self-compassion practices.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
30
Conclusions
The evidence presented in the current review offers preliminary support for the
efficacy of MBIs and MIPs in reducing symptom severity and increasing SC for patients with
PTSD, SAD or related symptomatology. It also suggests that integrating self-compassion
practices in the treatments for these patients may be feasible and acceptable across a wide
range of populations, treatment settings, and delivery methods. Additionally, the SCS may
have a potential use as an aid for clinicians seeking to discern which patients in SUD
treatment could benefit from self-compassion practices to facilitate therapeutic change.
However, given the lack of high-quality, large-scale trials, further research with
methodologically robust designs is needed to demonstrate the efficacy of increasing self-
compassion in the treatment of anxiety disorders and SUD. More research examining within-
person processes of change is needed to examine SCS’s potential to inform clinicians treating
patients with SUD.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
31
References
Alcoholics Anonymous. (2001). Alcoholics Anonymous (4th ed.). New York: A.A. World
Services, Inc.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorder, text revision (DSM-IV-TR). Washington, D.C.: American Psychiatric
Association.
Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and
empirical review. Clinical Psychology: Science and Practice, 10(2), 125-143.
doi:10.1093/clipsy.bpg015
Baer, R. A. (2014). Introduction to the core practices and exercises. In R. A. Baer (Ed.),
Mindfulness-based treatment approaches: Clinicians's guide to evidence base and
applications (2nd ed., pp. 3-25). London: Academic Press.
Beaumont, E., Galpin, A., & Jenkins, P. (2012). 'Being kinder to myself': A prospective
comparative study, exploring post-trauma therapy outcome measures, for two groups of
clients, receiving either cognitive behaviour therapy or cognitive behaviour therapy and
compassionate mind training. Counselling Psychology Review, 27(1), 31-43.
Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., . . . Devins, G.
(2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science
and Practice, 11(3), 230-241. doi:10.1093/clipsy.bph077
Blacker, M., Meleo-Meyer, M., Kabat-Zinn, J., & Santorelli, S. (2009). Stress reduction clinic
mindfulness-based stress reduction (MBSR) curriculum guide. Unpublished manuscript.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
32
Retrieved 26-04-2015, Retrieved from https://blackboard.bangor.ac.uk/bbcswebdav/pid-
1647087-dt-content-rid-3116323_1/xid-3116323_1
Bodhi, B. (Ed.). (2005). In the Buddha's words: An anthology of discourses from the Pali
canon. Somerville: Wisdom Publications.
Boersma, K., Håkanson, A., Salomonsson, E., & Johansson, I. (2015). Compassion focused
therapy to counteract shame, self-criticism and isolation. A replicated single case
experimental study for individuals with social anxiety. Journal of Contemporary
Psychotherapy, 45(2), 89-98. doi:10.1007/s10879-014-9286-8
Bowen, S., Chawla, N., & Marlatt, G. A. (2011). Mindfulness-based relapse prevention for
addictive behaviours: A clinician's guide. New York: The Guilford Press.
Brach, T. (2003). Het leven liefhebben door acceptatie [Radical Acceptance]. Utrecht:
Kosmos.
Cannon, W. B. (1929). Bodily changes in pain, hunger, fear and rage. Oxford: Appleton.
Centre for Reviews and Dissemination. (2009). Systematic reviews: CRD's guidance for
undertaking reviews in health care. York: University of York. Retrieved from
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUK
Ewjtr8HM3cbdAhWH16QKHZAeBq4QFjAAegQIARAC&url=https%3A%2F%2Fww
w.york.ac.uk%2Fmedia%2Fcrd%2FSystematic_Reviews.pdf&usg=AOvVaw3TR0y4OG
UfJUrTMRdyWB4q
Conger, J. J. (1956). Reinforcement theory and the dynamics of alcoholism. Quarterly
Journal of Studies on Alcohol, 17, 296-305.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
33
Crane, R. S., Brewer, J., Feldman, C., Kabat-Zinn, J., Santorelli, S., Williams, J. M. G., &
Kuyken, W. (2016). What defines mindfulness-based programs? The warp and the weft.
Psychological Medicine, 47(6), 990-999. doi:10.1017/S0033291716003317
Critical Appraisal Skills Programme. (2018). CASP randomised controlled trial checklist.
Retrieved from http://casp-uk.net/wp-content/uploads/2018/01/CASP-Systematic-
Review-Checklist_2018.pdf
Curran, P. J., & Bauer, D. J. (2011). The disaggregation of within-person and between-person
effects in longitudinal models of change. Annual Review of Psychology, 62(1), 583-619.
doi:10.1146/annurev.psych.093008.100356
Daley, D. C., & Moss, H. B. (2003). Anxiety disorders and chemical dependency. Dual
disorders (3rd ed., ). Center City, Minnesota: Hazelden.
Didonna, F. (2009). Introduction: Where new and old paths to dealing with suffering meet. In
F. Didonna (Ed.), Clinical handbook of mindfulness (pp. 1-14). New York: Springer
Science+Business Media.
Feldman, C., & Kuyken, W. (2011). Compassion in the landscape of suffering. Contemporary
Buddhism, 12(1), 143-155.
Fisher, L. D., Dixon, D. O., Herson, J., Frankowski, R. K., Hearron, M. S., & Peace, K. E.
(1990). Intention to treat in clinical trials. In K. E. Peace (Ed.), Statistical issues in drug
research and development. (pp. 331–50). New York: Marcel Dekker.
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for
PTSD: Emotional processing of traumatic experiences. New York: Oxford University
Press.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
34
Garland, E. (2013). Mindfulness-oriented recovery enhancement for addiction, stress and
pain. Washington, DC: NASW Press.
Gilbert, P. (2010). Compassion focused therapy. Hove: Routledge.
Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame
and self‐criticism: Overview and pilot study of a group therapy approach. Clinical
Psychology & Psychotherapy, 13(6), 353-379. doi:10.1002/cpp.507
Goldin, P. R., Ziv, M., Jazaieri, H., Werner, K., Kraemer, H., Heimberg, R. G., & Gross, J. J.
(2012). Cognitive reappraisal self-efficacy mediates the effects of individual cognitive-
behavioral therapy for social anxiety disorder. Journal of Consulting and Clinical
Psychology, 80(6), 1034-1040. doi:10.1037/a0028555
Greeson, J., & Brantley, J. (2009). Mindfulness and anxiety disorders: Developing a wise
relationship with the inner experience of fear. In F. Didonna (Ed.), Clinical handbook of
mindfulness (pp. 171-188). New York, NY: Springer New York. doi:10.1007/978-0-387-
09593-6_11
Harris, K. M., & Edlund, M. J. (2005). Use of mental health care and substance abuse
treatment among adults with co-occurring disorders. Psychiatric Services, 56(8), 954-
959. doi:10.1176/appi.ps.56.8.954
Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy.
New York: Guilford Press.
Hayes, S. C. (2016). Acceptance and commitment therapy, relational frame theory, and the
third wave of behavioral and cognitive therapies – republished article
doi://doi.org/10.1016/j.beth.2016.11.006
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
35
Held, P., & Owens, G. P. (2015). Effects of Self‐Compassion workbook training on Trauma‐
Related guilt in a sample of homeless veterans: A pilot study. Journal of Clinical
Psychology, 71(6), 513-526. doi:10.1002/jclp.22170
Henderson, L., & Gilbert, P. (2011). The compassionate-mind guide to building social
confidence: Using compassion-focused therapy to overcome shyness and social anxiety.
Oakland: New Harbinger Publications.
Higgins, J. P. T., & Green, S. (2011). Cochrane handbook for systematic reviews of
interventions. Retrieved from http://www.handbook.cochrane.org
Hippocrates. (1886). The genuine works of hippocrates (vol. 2). New York: Wood W.
Hjeltnes, A., Molde, H., Schanche, E., Vøllestad, J., Lillebostad Svendsen, J., Moltu, C., &
Binder, P. (2017). An open trial of mindfulness‐based stress reduction for young adults
with social anxiety disorder. Scandinavian Journal of Psychology, 58(1), 80-90.
doi:10.1111/sjop.12342
Hoffart, A., Øktedalen, T., & Langkaas, T. F. (2015). Self-compassion influences PTSD
symptoms in the process of change in trauma-focused cognitive-behavioral therapies: A
study of within-person processes. Frontiers in Psychology, 6
doi:10.3389/fpsyg.2015.01273
Hölzel, B. K., Lazar, S. W., Gard, T., Schuman-Oliver, Z., Vago, D. R., & Ott, U. (2011).
How does mindfulness meditation work? proposing mechanisms of action from a
conceptual and neural perspective. Perspectives on Psychological Science, 6(537)
doi:10.1177/174569161149671
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
36
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining
meaningful change in psychotherapy research. Journal of Consulting and Clinical
Psychology, 59(1), 12-19. doi:10.1037//0022-006X.59.1.12
Jazaieri, H., Goldin, P. R., Werner, K., Ziv, M., & Gross, J. J. (2012). A randomized trial of
MBSR versus aerobic exercise for social anxiety disorder. Journal of Clinical
Psychology, 68(7), 715-731. doi:10.1002/jclp.21863
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future.
Clinical Psychology: Science and Practice, 10(2), 144-156. doi:10.1093/clipsy.bpg016
Kabat-Zinn, J. (2005). Full catastrophe living: How to cope with stress, pain and illness using
mindfulness meditation (15th ed.). New York: Bantam Dell.
Kahl, K. G., Winter, L., & Schweiger, U. (2012). The third wave of cognitive behavioural
therapies: What is new and what is effective? Current Opinion in Psychiatry, 25(6), 522-
528. doi:10.1097/YCO.0b013e328358e531
Kearney, D. J., Malte, C. A., McManus, C., Martinez, M. E., Felleman, B., & Simpson, T. L.
(2013). Loving‐Kindness meditation for posttraumatic stress disorder: A pilot study.
Journal of Traumatic Stress, 26(4), 426-434. doi:10.1002/jts.21832
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005).
Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national
comorbidity survey replication. Archives of General Psychiatry, 62(6), 593-602.
doi:10.1001/archpsyc.62.6.593
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
37
Kocovski, N. L., Segal, Z. V., & Battista, S. R. (2009). Mindfulness and psychopathology:
Problem formulation. In F. Didonna (Ed.), Clinical handbook of mindfulness (pp. 85-98).
New York, NY: Springer New York. doi:10.1007/978-0-387-09593-6_6
Koster, F. (2012). Bevrijdend inzicht: Een kennismaking met boeddhistische psychologie,
mindfulness en inzichtmeditiatie
[Liberating insight: An introduction to Buddhist psychology, mindfulness and insight
meditation] (6th ed.). Rotterdam: Asoka.
Koszycki, D., Thake, J., Mavounza, C., Daoust, J., Taljaard, M., & Bradwejn, J. (2016).
Preliminary investigation of a mindfulness-based intervention for social anxiety disorder
that integrates compassion meditation and mindful exposure. The Journal of Alternative
and Complementary Medicine, 22(5), 363-374. doi:10.1089/acm.2015.0108
Kushner, M. G., Sher, K. J., & Beitman, B. D. (1990). The relation between alcohol problems
and the anxiety disorders. The American Journal of Psychiatry, 147(6), 685-95.
Retrieved from https://search.proquest.com/docview/220477308?accountid=14874
Kuyken, W., & Evans, A. C. (2014). Mindfulness-based relapse cognitive therapy for
recurrent depression. In A. E. Baer (Ed.), Mindfulness-based treatment approaches:
Clinicians's guide to evidence base and applications (2nd ed., pp. 29-60). London:
Academic Press.
Kuyken, W., Watkins, E., Holden, E., White, K., Taylor, R. S., Byford, S., . . . Dalgleish, T.
(2010). How does mindfulness-based cognitive therapy work? Behaviour Research and
Therapy, 48(11), 1105-1112. doi://doi.org/10.1016/j.brat.2010.08.003
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
38
Leaviss, J., & Uttley, L. (2015). Psychotherapeutic benefits of compassion-focused therapy:
An early systematic review. Psychological Medicine, 45(5), 927-945.
doi:10.1017/S0033291714002141
Li, W., Howard, M. O., Garland, E. L., McGovern, P., & Lazar, M. (2017). Mindfulness
treatment for substance misuse: A systematic review and meta-analysis. Journal of
Substance Abuse Treatment, 75, 62-96.
Lindahl, J. R., Fisher, N. E., Cooper, D. J., Rosen, R. K., & Britton, W. B. (2017). The
varieties of contemplative experience: A mixed-methods study of meditation-related
challenges in western buddhists. PLoS One, 12(5), e0176239.
doi:10.1371/journal.pone.0176239
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder.
New York: Guilford Press.
Ma, H. (2006). An alternative method for quantitative synthesis of single-subject researches.
Behavior Modification, 30(5), 598-617. doi:10.1177/0145445504272974
MacBeth, A., & Gumley, A. (2012). Exploring compassion: A meta-analysis of the
association between self-compassion and psychopathology. Clinical Psychology Review,
32(6), 545-552. doi:10.1016/j.cpr.2012.06.003
Marlatt, G. A., & Donovan, D. M. (Eds.). (2008). Relapse prevention: Maintenance strategies
in the treatment of addictive behaviors (2nd ed.). New York: The Guilford Press.
McGovern, M. P., Xie, H., Segal, S. R., Siembab, L., & Drake, R. E. (2006). Addiction
treatment services and co-occurring disorders: Prevalence estimates, treatment practices,
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
39
and barriers. Journal of Substance Abuse Treatment, 31(3), 267-275.
doi:10.1016/j.jsat.2006.05.003
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for
systematic reviews and meta-analyses: The PRISMA statement. PLOS Medicine, 6(7),
e1000097. Retrieved from https://doi.org/10.1371/journal.pmed.1000097
Moos, R. H. (2009). Addictive disorders in context: Principles and puzzles of effective
treatment and recovery. In G. A. Marlatt, & K. Witkiewitz (Eds.), Addictive behaviors:
New readings on etiology, prevention, and treatment (pp. 537-558) American
Psychological Association. doi:10.1037/11855-021
Narcotics Anonymous. (2008). Narcotics Anonymous (6th ed.). Chatsworth: NA World
Services, Inc.
National Institute on Drug Abuse. (2018). Principles of drug treatment: A research-based
guide (3rd ed.). Bethesda MD, United States: National Institute on Drug Abuse.
Retrieved from https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/675-principles-of-
drug-addiction-treatment-a-research-based-guide-third-edition.pdf
Neff, K. (2003a). The development and validation of a scale to measure self-compassion. Self
and Identity, 2(3), 223-250. doi:10.1080/15298860309027
Neff, K. (2003b). Self-compassion: An alternative conceptualization of a healthy attitude
toward oneself. Self and Identity, 2(2), 85-101. doi:10.1080/15298860309032
Neff, K. (2016). The self-compassion scale is a valid and theoretically coherent measure of
self-compassion. Mindfulness, 7(1), 264-274. doi:10.1007/s12671-015-0479-3
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
40
Neff, K. (2018). Self-compassion publications. Retrieved from http://self-compassion.org/the-
research/
Neff, K., Rude, S., & Kirkpatrick, K. (2007). An examination of self-compassion in relation
to positive psychological functioning and personality traits. Journal of Research in
Personality, 41(4), 908-916. doi://doi.org/10.1016/j.jrp.2006.08.002
Öst, L. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and
meta-analysis. Behaviour Research and Therapy, 46(3), 296-321.
doi://doi.org/10.1016/j.brat.2007.12.005
Penberthy, J. K., Konig, A., Gioia, C. J., Rodríguez, V. M., Starr, J. A., Meese, W., . . .
Natanya, E. (2015). Mindfulness-based relapse prevention: History, mechanisms of
action, and effects. Mindfulness, 6(2), 151-158.
Raes, F., Pommier, E., Neff, K. D., & Van Gucht, D. (2011). Construction and factorial
validation of a short form of the Self‐Compassion scale. Clinical Psychology &
Psychotherapy, 18(3), 250-255. doi:10.1002/cpp.702
Rodebaugh, T. L., Holaway, R. M., & Heimberg, R. G. (2004). The treatment of social
anxiety disorder. Clinical Psychology Review, 24(7), 883-908.
doi:10.1016/j.cpr.2004.07.007
Salzberg, S. (2011). Liefdevolle vriendelijkheid: Een ander perspectief op geluk
[Lovingkindness] (K. Merkus Trans.). (5th ed.). Nieuwerkerk a/d IJssel: Ashoka.
SAMSHA. (2005). Substance abuse treatment for persons with co-occurring disorders.
Rockville, MD: U.S. Dept. of Health and Human Services, Substance Abuse and Mental
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
41
Health Services Administration, Center for Substance Abuse Treatment. Retrieved from
http://purl.access.gpo.gov/GPO/LPS72393
Schmidt, N. B., Richey, J. A., Zvolensky, M. J., & Maner, J. K. (2007). Exploring human
freeze responses to a threat stressor. Journal of Behavior Therapy and Experimental
Psychiatry, 39(3), 292-304. doi:10.1016/j.jbtep.2007.08.002
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness en cognitieve therapie
bij depressie [Mindfulness-based cognitive therapy for depression: Second edition] (R.
Van de Weijer, S. Wagenaar & J. Langeveld Trans.). (2nd ed.). Amsterdam: Uitgeverij
Nieuwezijds.
Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of
mindfulness. Journal of Clinical Psychology, 63(3) doi:10.1002/jclp.20237
Shonin, E., Van Gordon, W., Compare, A., Zangeneh, M., & Griffiths, M. (2015). Buddhist-
derived loving-kindness and compassion meditation for the treatment of
psychopathology: A systematic review. Mindfulness, 6(5), 1161-1180.
doi:10.1007/s12671-014-0368-1
Stöfsel, M., & Mooren, T. (2017). Trauma en persoonlijkheidsproblematiek [Trauma and
personality functioning]. Houten: Bohn, Staffleu en van Loghum.
United Nations Office on Drugs and Crime. (2017). World drug report 2017 - executive
summary - conclusions and policy implications. New York: United Nations.
doi:10.18356/66312961-en Retrieved from
https://www.unodc.org/wdr2017/field/Booklet_1_EXSUM.pdf
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
42
Valdez, C., & Lilly, M. (2016). Self-compassion and trauma processing outcomes among
victims of violence. Mindfulness, 7(2), 329-339. doi:10.1007/s12671-015-0442-3
Van Dam, N. T., Sheppard, S. C., Forsyth, J. P., & Earleywine, M. (2010). Self-compassion is
a better predictor than mindfulness of symptom severity and quality of life in mixed
anxiety and depression. Journal of Anxiety Disorders, 25(1), 123-130.
doi:10.1016/j.janxdis.2010.08.011
Van den Bree, M., Bonner, A., Taylor, P. J., & Shelton, K. H. (2009). Risk factors for
homelessness: Evidence from a population-based study. Psychiatric Services, 60(4), 465-
472. doi:10.1176/ps.2009.60.4.465
Walsh, R., & Roche, L. (1979). Precipitation of acute psychotic episodes by intensive
meditation in individuals with a history of schizophrenia. The American Journal of
Psychiatry, 136(8), 1085-1086.
Witkiewitz, K., Bowen, S., Harrop, E. N., Douglas, H., Enkema, M., & Sedgwick, C. (2014).
Mindfulness-based treatment to prevent addictive behavior relapse: Theoretical models
and hypothesized mechanisms of change. Substance use & Misuse, 49(5), 513-524.
doi:10.3109/10826084.2014.891845
Witkiewitz, K., & Marlatt, G. A. (2009). Relapse prevention for alcohol and drug problems:
That was Zen, this is Tao. In G. A. Marlatt, & K. Witkiewitz (Eds.), Addictive
behaviours: New readings on etiology, prevention, and treatment (pp. 403-427).
Washington, D.C.: American Psychological Association.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
43
World Health Organization. (2014). Global status report
on alcohol and health. Geneva, Switserland: WHO. Retrieved from
http://www.who.int/iris/bitstream/10665/112736/1/9789240692763_eng.pdf
Young, R. D., Oei, T. P., & Knight, R. G. (2010). The tension reduction hypothesis revisited:
An alcohol expectancy perspective. British Journal of Addiction, 85(1), 31-40.
doi:10.1111/j.1360-0443.1990.tb00621.x
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
44
APPENDIX A
Tables
Table 1
Primary Anxiety Disorders, Clinical Descriptions, and Lifetime Prevalence (Greeson &
Brantley, 2009, p. 173)
Diagnostic Category Clinical Description Lifetime Prevalence*
Generalised anxiety disorder Persistent, pervasive worry
that is difficult to control
5%
Obsessive-compulsive
disorder
Obsessive thinking about
possible threats to safety and
compulsive ritualistic
behaviours to allay fear
2.5%
Panic disorder Southern, overwhelming,
intense fear of something
going wrong
1.0-3.5%
Post-traumatic stress disorder Intrusive thoughts,
hyperarousal, and re-
experience of past trauma
8%
Social anxiety disorder Fear of negative social
evaluation
Up to 13%
Specific phobia Fear of a specific object or
situation
7-11%
* Obtained from DSM-IV-TR, American (Young et al., 2010) Psychiatric Association (2000)
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
45
Table 2
Summary description of study designs, populations, interventions and main outcomes
Study N Design Population Intervention Control
group
Measures Main Outcomes
Held & Owens
2015
47 RCT Homeless
veterans in
transitional
housing
Self-
compassion
workbook
Stress
inoculation
workbook
THS, SCS,
TRGI, PCL-
S
Increased levels of self-compassion and
reduced levels of trauma-related guilt for
both groups. No significant differences
found in PTSD severity.
Hoffart et al.
2015
65 RCT PTSD patients
in residential
care
Prolonged
exposure
modified to
include
imagery re-
scripting
Standard
prolonged
exposure
PSS-SR, SCS 5 of the SCS-subscales demonstrated
change independent of therapy form: self-
kindness, mindfulness, self-judgement,
isolation and over-identification; only
common humanity did not. These changes
had a within-person effect on PTSD
symptoms: patients with higher initial self-
judgement showed a stronger within-person
relationship between self-judgement and
subsequent PTSD symptoms. Within-person
variations in PTSD symptoms did not
predict variations in self-compassion
components.
Jazaieri et al.
2012
56 RCT Patients with
principal
diagnosis of
SAD
MBSR vs.
Aerobic
Exercise
Non-
randomised
healthy
controls and
untreated
participants
with SAD
KIMS,
LSAS-SR,
SIAS-S,
BDI-II, PSS-
4, RSE,
SLWLS,
SCS, ULS-8
Comparable significant changes in both
treatment groups, both post treatment and at
3 month follow-up: reductions in social
anxiety and increases in subjective well-
being.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
46
Table 2 (continued)
Study N Design Population Intervention Control
group
Measures Main Outcomes
Koszycki et al.
2016
39 RCT Patients
with SAD
MBI-SAD Waitlist LSAS, SPIN,
GCI-S, BDI-
II, SAS-SR,
SCS-SF,
FFMQ
MBI-SAD feasible and acceptable. Greater
improvement in social anxiety symptom
severity, and social adjustment for MBI-
SAD group. Enhanced self-compassion
compared to WL. Gains maintained at 3-
month follow-up.
Valdez & Lily
2016
63 RCT Female
trauma
survivors
Negative
affect vs.
positive affect
processing
induction
Control
with
neutral
processing
induction
TLEQ, PCL-
C, SCS, BAI,
PANAS-X
At baseline less PTSD symptoms correlates
with greater over-all self-compassion. Post-
treatment greater the mindfulness and self-
kindness SCS-subscales correlated with
greater less anxiety and negativity in C;
greater self-kindness correlated with less
negative affectivity and mindfulness
correlated with less anxiety and negative
affectivity, and greater positive affectivity in
NA; and greater common humanity
correlated with more anxiety, and greater
self-kindness correlated with more anxiety
and positive affectivity in PA.
Boersma et al.
2015
6 Replicated
single case
design
University
students
suffering
from SA
CFT None SPSQ, SIAS,
SCS,
treatment
evaluation,
diary ratings
of shame,
self-criticism
and self-
compassion
CFT effective for three participants,
probably effective for one and effectiveness
questionable for two participants. Five
participants showed reliable improvement
on SCS-scores, mixed results for SA
symptoms. Half of the participants showed
clinically significant improvement on SPSQ
outcomes. Half of participants “very
satisfied” with treatment, the other half
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
47
Table 2 (continued)
Study N Design Population Intervention Control
group
Measures Main Outcomes
“quite satisfied”; half of participants found
they had improved “a lot”, the other half
“somewhat”.
Hjeltnes et al.
2017
53 Longitudinal
follow-up
study
University
students with
SAD or social
anxiety
problems
MBSR None SPS, SCL-90-
R, FFMQ,
SCS, RSE
Large to moderate effect sizes for SAD
symptoms and global psychological distress.
Moderate to large effects for self-
compassion. Significant positive
associations between changes in self-
compassion and self-esteem; significant
negative association between changes in SA
symptoms and both self-compassion and
self-esteem. Clinically significant or reliable
change for two thirds of participants.
Kearney et al.
2013
48 Longitudinal
follow-up
study
Veterans with
PTSD
LKM None PSS-I, SCS,
PROMIS,
CLS, FFMQ
LKM highly acceptable for veterans: 74%
completed treatment. Larger effect sizes for
increased self-compassion, medium to large
effect size for increase in mindfulness post-
treatment and at follow-up. Large effect size
for reduction in PTSD symptom and
medium effect size for depression found at
3-month follow-up. Evidence for enhanced
self-compassion as mediator of reductions in
both PTSD and depression symptoms.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
48
Table 2 (continued)
Study N Design Population Intervention Control
group
Measures Main Outcomes
Beaumont et
al. 2012
32 Comparative
interventional
study
Convenience
sample,
referred for
CBT after
traumatic
incident
CBT
combined
with CMT
CBT HADS, IES,
SCS-SF
Highly significant reduction post therapy in
symptoms of avoidant behaviour, intrusive
thoughts, hyper-arousal symptoms, anxiety
and depression for both groups; no
significant difference between groups.
Highly significant increase in self-
compassion for both groups; combined
CBT/CMT group reported significantly
higher overall SCS-scores.
Note: Design: RCT = Randomised Controlled Trial.
Population: PTSD = Post-Traumatic Stress Disorder; SAD = Social Anxiety Disorder,
Intervention: CBT = Cognitive Behavioural Therapy; CMT = Compassionate Mind Training; CFT = Compassion Focussed Therapy; MBSR =
Mindfulness-Based Stress Reduction; LKM = Loving-Kindness Meditation; MBI-SAD = Mindfulness-Based Intervention for Social Anxiety
Disorder.
Measures: HADS = Hospital Anxiety and Depression Scale; Impact of Events Scale; SCS-SF = Self-Compassion Scale - Short Form; SPSQ =
Social Phobia Screening Questionnaire; SIAS = Social Interaction Anxiety Scale; SCS = Self-Compassion Scale; THS = Trauma History Screen;
TRGI = Trauma-Related Guilt Inventory; PCL-S = PTSD Checklist-Specific Stressor Version; SPS = Social Phobia Scale;
SCL-90-R = Symptom Checklist 90 Revised; FFMQ = Five Facet Mindfulness Questionnaire; RSE = Rosenberg Self Esteem Scale; PSS-R =
PTSD Symptom Scale - Self-Report; KIMS = Kentucky Inventory of Mindfulness Scale; LSAS-SR = Liebowitz Social Anxiety Scale - Self-
Report; SIAS-S = Social Interaction Anxiety Scale Straightforward Scale; BDI-II = Beck Depression Inventory - II; PSS-4 = Perceived Stress
Scale; SWLS = Satisfaction with Life Scale; ULS-8 = UCLA-8 Loneliness Scale; PSS-I = PTSD Symptom Scale Interview; PROMIS = Patient-
Reported Outcomes Measurement Information System; CLS = Compassionate Love Scale; SPIN = Social Phobia Inventory; GCI-S = Clinical
Global Impression–Severity Scale; SAS-SR = Social Adjustment Self-Report Scale; TLEQ = Traumatic Life Events Questionnaire; PCL-C =
PTSD Checklist-`civilian Version; BAI = Beck Anxiety Inventory; PANAS-X = Positive and Negative Affect Schedule – Expanded Form.
Main Outcomes: SA = Social Anxiety; SAD = Social Anxiety Disorder; AE = Aerobic Exercise; WL = Waitlist; C = Control; NA = Negative
Affect processing induction; PA = Positive Affect processing induction.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
49
Table 3
Summary description of disorders, populations, treatment and (self-)compassion components incorporated in treatments under examination
Study Disorder /
symptomatology
Clinical / non-
clinical
population
Intervention(s)
and control
group
Therapist
details
Duration of
intervention
Treatment
adherence
monitoring
and
supervision
(Self-)compassion
or LKM component
Held & Owens
2015
PTSD / Trauma-
related guilt
Non-clinical;
homeless
veterans living
in transitional
housing facility
Self-
compassion
workbook;
Stress-
inoculation
workbook
NA (self-
administered
via workbook,
introductory
group session)
4 weeks;
participants
requested to
read workbook
sections and
practice
exercises for
min. of 5-15
min. daily
Use of
workbooks
verified
Compassionate
awareness of
present moment
experience;
compassionate
responding to own
experience; writing
compassionate letter
to self
Hoffart et al.
2015
PTSD Clinical in
residential care
Prolonged
exposure
modified to
include
imagery re-
scripting
(individual)
Certified,
experienced
(> 10 years)
CBT therapists
10 weekly 90
min. sessions
Treatment
adherence
monitored;
individual
and group
supervision
Imagined
interaction of
‘Current Self ‘
providing care and
emotional support in
various ways for
‘Traumatised Self’
Jazaieri et al.
2012
SAD Clinical
(healthy, non-
randomised
controls
included in
analyses)
MBSR vs. AE
MBSR:
experienced
teachers;
training NS
AE instructors:
NS
MBSR: 8
weekly 2 ½ to 3
hour group
sessions; one all
day practice
session; formal
and informal
homework
practice
NS No explicit (self-)
compassion or LKM
practice included
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
50
Table 3 continued
Study Disorder /
symptomatology
Clinical / non-
clinical
population
Intervention(s)
and control
group
Therapist
details
Duration of
intervention
Treatment
adherence
monitoring
and
supervision
(Self-)compassion
or LKM component
AE: 1 weekly
group session,
plus minimum
of 2 individual
sessions weekly
Koszycki et al.
2016
SAD Clinical MBI-SAD Registered
psychologist
with expertise
in treating
DAD, formal
training in
MBIs and a
personal
mindfulness
practice.
12 weekly 2-
hour group
sessions
NS LKM; self-
compassion
meditations as
described by Brach
(2003); psycho-
education around
self-compassion and
its relation to both
SAD and general
well-being
Valdez & Lily
2016
Trauma-
survivors /
PTSD
Non-clinical; all
female sample
“Analytic” vs.
“Experimental”
processing
induction vs.
“neutral”
control
induction
Undergraduate
research
assistant;
trauma specific
pervasive
thinking
interview
administered
by clinical
psychologist
1.5 hour
individual
session
NS No explicit (self-)
compassion or LKM
practice included
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
51
Table 3 continued
Study Disorder /
symptomatology
Clinical / non-
clinical
population
Intervention(s)
and control
group
Therapist
details
Duration of
intervention
Treatment
adherence
monitoring
and
supervision
(Self-)compassion
or LKM component
Boersma et al.
2014
SA / SAD Non-clinical;
screened for
fulfilment of
DSM-IV SA
criteria
Individual CFT Psychology
students
finalising
clinical training
8 weekly 1-hour
sessions
Adherence
of
manualised
intervention
NS; weekly
supervision.
“Safe Place”
imagery exercise;
generation
compassionate
thoughts exercise;
experiencing
compassion from
others exercise;
feeling compassion
for others exercise;
writing
compassionate letter
to self
Hjeltnes et al.
2017
SAD Non-clinical MBSR Clinical
psychologist;
formal MBSR
teacher training
specified for 1
of 6 therapists
8 weekly 2 ½-3
hour group
sessions; all day
practice session;
formal and
informal
homework
practice
NS No explicit (self-)
compassion or LKM
practice included
Kearney et al.
2013
PTSD Clinical LKM Experienced
mediation
teachers;
training NS
12 weekly 90
minute group
sessions
NS LKM
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
52
Table 3 continued
Study Disorder /
symptomatology
Clinical / non-
clinical
population
Intervention(s)
and control
group
Therapist
details
Duration of
intervention
Treatment
adherence
monitoring
and
supervision
(Self-)compassion
or LKM component
Beaumont et
al. 2012
PTSD / Trauma
related
symptoms
Non-clinical;
experienced
traumatic
incident
Individual
CBT coupled
with CMT
Single, CBT-
accredited
therapist
Up to 12
sessions;
duration NS
NS Challenging of
“internal bully”
using imagery;
compassionate letter
writing; and
grounding work
(using memory
triggers associated
with safety and
relaxation)
Note: Disorder / Symptomatology: PTSD = Post-Traumatic Stress Disorder; SA = Social Anxiety; SAD = Social Anxiety Disorder
Clinical / non-clinical population: DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, America Psychiatric Association.
Intervention and control group: CBT = Cognitive Behavioural Therapy; CMT = Compassionate Mind Training; CFT = Compassion Focussed
Therapy; MBSR = Mindfulness-Based Stress Reduction; AE = Aerobic Exercise; LKM = Loving-Kindness Meditation; MBI-SAD =
Mindfulness-Based Intervention for Social Anxiety Disorder.
Therapist details: NS = not specified.
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
53
Table 4
Summary of outcomes of quality assessment with CRD-tool, denoting quality criteria and related potential for confounding and bias.
Randomisation
(allocation bias) Baseline
comparability
(confounding)
Eligibility
(selection bias) Blinding
(detection bias) Withdrawals
(attrition bias) Outcomes
(reporting
bias)
Study
Tru
ly
ran
do
m
All
oca
tio
n
con
ceal
men
t
Nu
mb
er
stat
ed
Pre
sen
ted
Ach
iev
ed
Eli
gib
ilit
y
crit
eria
spec
ifie
d
Co
-
inte
rven
tio
ns
iden
tifi
ed
Ass
esso
rs
Ad
min
istr
ati
on
Par
tici
pan
ts
Pro
ced
ure
asse
ssed
80
% i
n f
inal
anal
ysi
s
Rea
son
s
stat
ed
Un
exp
ecte
d
dro
p-o
uts
Inte
nti
on
to
trea
t
Oth
er
ou
tco
mes
Held &
Owens
2015
NS NA
Hoffart et
al. 2015
Jazaieri et
al. 2012
Koszycki
et al. 2016
NA
Valdez &
Lily 2016
Hoffart et
al. 2015
Boersma
et al. 2015
NA NA NA NA NA NA NA NA NA
Hjeltnes et
al. 2017
NA NA NA NA NA NA NA NA NA NS NS
Kearney et
al. 2013
NA NA NA NA NA NA NS NA NA
Beaumont
et al. 2012
NA NA NA NS
Note: = yes (item adequately addressed); = no (item not adequately addressed); = partially (item partially addressed; NS = not stated; NA = not applicable
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
54
APPENDIX B
Interventions for anxiety disorders and Self-Compassion Scale screening and selection tool
Date:
Author name(s): Year:
Title: Journal:
-----------------------------------------------------------------------------------------------------------------
Patient population
Include Exclude
Adults diagnosed with an anxiety disorder Studies including children or minors
No AD diagnosis or symptoms
Intervention(s)
Include Exclude
Conducted in clinical or outpatient setting No experiential treatment component
Not peer reviewed
Outcomes
Must include Exclude
Self-Compassion Scale SCS not used
Anxiety symptom severity Anxiety symptoms not assessed
May include
Feasibility Quality of life
Treatment acceptability Treatment adherence
Study design
Include Exclude
Examines AD intervention Not examining AD
Systematic review or meta-analysis
Overall decision INCLUDED EXCLUDED
NOTES
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
55
APPENDIX C
CRD informed research study quality assessment tool
Author name/Study ID:
Quality item:
Randomisation (check for allocation bias)
Was the method used to assign participants to the treatment groups truly random?
Was the allocation of treatment concealed?
Was the number of participants randomised stated?
Comparability (check for confounding)
Where details of baseline comparability presented?
Was baseline comparability achieved?
Blinding (check for detection bias)
Were outcome assessors blinded to treatment allocation?
Were individuals who administered the intervention blinded to treatment allocation?
Were participants blinded to treatment allocation?
Was the success of the blinding procedures assist?
Withdrawals (check for attrition bias)
Were > 80% of participants randomised included in the final analysis?
Were reasons for participant withdrawals stated?
Was there any unexpected dropouts in either group?
Was an intention to treat analysis included?
Outcomes (check for outcome reporting bias)
is there evidence that more outcomes were measured than were reported?
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
56
APPENDIX D
CASP RCT CHECKLIST
CASP Checklist: 11 questions to help you make sense of a Randomised
Controlled Trial
How to use this appraisal tool: Three broad issues need to be considered when appraising a trial:
Are the results of the study valid? (Section A)
What are the results? (Section B)
Will the results help locally? (Section C)
The 11 questions on the following pages are designed to help you think about these issues systematically. The
first three questions are screening questions and can be answered
quickly. If the answer to both is “yes”, it is worth proceeding with the remaining questions. There is
some degree of overlap between the questions, you are asked to record a “yes”, “no” or “can’t tell”
to most of the questions. A number of italicised prompts are given after
each question. These are designed to remind you why the question is important. Record your reasons
for your answers in the spaces provided.
About: These checklists were designed to be used as educational pedagogic tools, as part of a workshop
setting, therefore we do not suggest a scoring system. The core CASP checklists (randomised controlled
trial & systematic review) were based on JAMA 'Users’ guides to the medical literature 1994 (adapted
from Guyatt GH, Sackett DL, and Cook DJ), and piloted with health care practitioners.
For each new checklist, a group of experts were assembled to develop and pilot the checklist and the
workshop format with which it would be used. Over the years overall adjustments have been made to
the format, but a recent survey of checklist users reiterated that the basic format continues to be
useful and appropriate.
Referencing: we recommend using the Harvard style citation, i.e.: Critical Appraisal Skills Programme
(2018). CASP (insert name of checklist i.e. Randomised Controlled Trial) Checklist. [online] Available at:
URL. Accessed: Date Accessed.
©CASP this work is licensed under the Creative Commons Attribution – Non-Commercial- Share A like. To view a copy of this
license, visit http://creativecommons.org/licenses/by-nc- sa/3.0/ www.casp-uk.net
Critical Appraisal Skills Programme (CASP) part of Better Value Healthcare Ltd www.casp-uk.net
Section A: Are the results of the trial valid?
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
57
Is it worth continuing?
1. Did the trial address a clearly focused issue?
Yes HINT: An issue can be ‘focused’ In terms of • the population studied
Can’t Tell
No
• the intervention given
the comparator given • the outcomes considered
2. Was the assignment of
patients to treatments Yes HINT: Consider
how this was carried out randomised? Can’t Tell
No
was the allocation sequence concealed
from researchers and patients
3. Were all of the patients
who entered the trial Yes HINT: Consider
• was the trial stopped early properly accounted for at
its conclusion? Can’t Tell
No
• were patients analysed in the groups to which they were randomised
Comments:
Comments:
Comments:
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
58
Section B: What are the results?
4. Were patients, health
workers and study personnel
‘blind’ to treatment?
5. Were the groups similar at
the start of the trial
Yes
Can’t Tell
No
Yes HINT: Consider
• other factors that might affect the
6. Aside from the experimental
intervention, were the groups treated equally?
Can’t Tell
No
Yes
Can’t Tell
No
outcome, such as; age, sex, social class
Comments:
Comments:
Comments:
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
59
Comments:
Section C: Will the results help locally?
7. How large was the treatment effect? HINT: Consider
what outcomes were measured
Is the primary outcome clearly specified
what results were found for each outcome
8. How precise was the estimate of the treatment
effect? HINT: Consider
what are the confidence limits
9. Can the results be applied to
the local population, or in
Yes HINT: Consider whether
the patients covered by the trial are your context? Can’t Tell
No
similar enough to the patients to whom
you will apply this
how they differ
10. Were all clinically important
outcomes considered? Yes HINT: Consider whether
there is other information you would Can’t Tell
No
like to have seen
if not, does this affect the decision
Comments:
Comments:
Comments:
SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375
60
11. Are the benefits worth the
harms and costs? Yes HINT: Consider
even if this is not addressed by the Can’t Tell
No
trial, what do you think