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Psychotherapy Research
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Self-compassion and fear of self-compassion interact

to predict response to eating disorders treatment: A
preliminary investigation
a

Allison C. Kelly , Jacqueline C. Carter , David C. Zuroff & Sahar Borairi

Department of Psychiatry , Toronto General Hospital , Toronto, Ontario , Canada

Department of Psychology , McGill University , Montreal , Quebec , Canada

Department of Psychology , York University , Toronto, Ontario , Canada

Published online: 24 Aug 2012.

To cite this article: Allison C. Kelly , Jacqueline C. Carter , David C. Zuroff &
Sahar Borairi (2013) Self-compassion and fear
of self-compassion interact to predict response to eating disorders treatment: A
preliminary investigation, Psychotherapy
Research, 23:3, 252-264, DOI: 10.1080/10503307.2012.717310
To link to this article: http://dx.doi.org/10.1080/10503307.2012.717310

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Psychotherapy Research, 2013
Vol. 23, No. 3, 252#264, http://dx.doi.org/10.1080/10503307.2012.717310

Self-compassion and fear of self-compassion interact to predict

response to eating disorders treatment: A preliminary investigation

ALLISON C. KELLY1*, JACQUELINE C. CARTER1, DAVID C. ZUROFF2, &

SAHAR BORAIRI3
1

Department of Psychiatry, Toronto General Hospital, Toronto, Ontario, Canada;

2Department of Psychology, McGill
University, Montreal, Quebec, Canada & 3Department of Psychology, York University,
Toronto, Ontario, Canada

Downloaded by [Laurentian University] at 23:21 07 December 2014

(Received 29 January 2012; revised 15 June 2012; accepted 29 July 2012)

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

Keywords: self-compassion; fear of self-compassion; shame; eating disorders;

anorexia nervosa; bulimia nervosa

Although a significant proportion of people with an

eating disorder recover from their illness, many sufferers who enter treatment drop
out prematurely
(Surgenor, Macguire, & Beaumont, 2004), complete
the full course of treatment without full recovery
(Herzog et al., 1999), or leave treatment in remission
but subsequently relapse (Field et al., 1997). These
poor outcomes make it crucial to better identify and
target the factors that interfere with, or conversely
that promote, complete and sustained recovery from
an eating disorder (Carter, Blackmore, SutandarPinnock, & Woodside, 2004). In
addition to examining
the specific types of eating disorder pathology (e.g., the
presence of purging in anorexia nervosa) and general
psychopathology (e.g., a comorbid anxiety disorder)
associated with treatment response, researchers are
beginning to turn their attention to the personality and
emotional factors that might maintain eating disorder
symptomatology and interfere with successful and
sustainable psychotherapeutic outcomes (e.g., Tasca
et al., 2009; Carter, Kelly, & Norwood, 2012).
Shame and Eating Disorders
Goss and Gilbert (2002) suggested that feelings of
shame maintain many behaviors characteristic of an

eating disorder, including dietary restriction, excessive exercise, and self-

induced vomiting. Shame has
been defined as a painful self-conscious emotion in
which individuals see themselves as flawed, damaged,
and disgusting, and imagine that others share this
view (Tangney & Dearing, 2002). Gilbert (2007)
suggested that some individuals learn to engage in
self-critical thoughts and behaviors as a way of
managing shame, but their self-criticism has the ironic
effect of heightening and prolonging these feelings.
For example, people with eating disorders are highly
critical of their shape, weight, and eating behavior,
and often subject themselves to rigid dietary rules and
extreme compensatory actions. In bulimia nervosa
(BN), bingeing and purging behaviors can be seen as
providing a temporary relief from shame; however,
these secretive behaviors subsequently intensify selfdisgust and self-criticism,
propagating a cycle of
shame-symptoms-shame. A shame-symptoms-pride
cycle is thought to characterize anorexia nervosa
(AN). Here, dietary restriction and over-exercising
serve to distract from shame by yielding bursts of
pride; however, proud feelings quickly subside and
shame resurfaces unless symptoms escalate (Goss &
Allan, 2009). In restrictive and binge-purge eating
disorders alike, then, eating disorder symptoms can

Correspondence concerning this article should be addressed to Allison C. Kelly,

Toronto General Hospital, Psychiatry, 200 Elizabeth
Street, 9 Eaton North, Rm 216, Toronto, Ontario, M4J 3L5 Canada. Email:
allison.kelly@gmail.com
# 2013 Society for Psychotherapy Research
Downloaded by [Laurentian University] at 23:21 07 December 2014

Self-compassion
be seen as momentarily alleviating but ultimately
perpetuating feelings of shame.
In support of this model, individuals with eating
disorders have been found to report higher levels
of shame compared to healthy samples (Swan &
Andrews, 2003) and other psychiatric groups (Cook,
1994). There is also evidence that feelings of shame
are associated with more eating disturbance among
college students (Burney & Irwin, 2000; Hayaki,
Friedman, & Brownell, 2002) and among women
with an eating disorder history (Troop, Allan,
Serpell, & Treasure, 2008). Additional studies have
found that increased shame might be the mechanism
by which certain developmental experiences influence
subsequent eating disorder symptomatology (i.e.,
Murray & Waller, 2002). This empirical research
supports the theory that shame might contribute to
the development and maintenance of eating disorder
pathology, and might thus be both an important
target in treatment and outcome variable in research.

Self-Compassion and Eating Disorders

Gilbert (2005) proposed that the antidote to shame
is self-compassion. Self-compassion has been conceptualized as a response to
suffering characterized
by self-kindness rather than self-judgment, a mindful
rather than ruminative stance, and the perception
that one’s problems are part of the human condition
rather than isolating (Neff, 2003). Unlike selfesteem, which derives from how one
evaluates
one’s qualities and capabilities, self-compassion is
considered an unconditional form of positive selfregard that persists at times of
failure and disappointment (Gilbert, 2005, 2009; Neff & Vonk,
2009). According to Gilbert (2005, 2009), selfcompassion is a healthy, effective
way to regulate
shame because its effects are similar to those of
compassion from other people*namely, selfcompassion generates soothed, safe
feelings that
reduce the sense of threat inherent in shame. In
support of this view, Neff (2003) found that there are
stable differences in people’s propensities to respond
to their distress self-compassionately, and that those
higher in trait self-compassion are less anxious and
depressed, and enjoy greater social connectedness
and life satisfaction, even after controlling for their
self-esteem (Neff, 2003, 2004).
There have been no studies to our knowledge on
self-compassion in clinical eating disorder samples.
Two studies in non-clinical populations nevertheless
highlight the probable relevance of self-compassion
to eating disorders. Magnus, Kowalski, and McHugh
(2010) found that undergraduate female exercisers
higher in trait self-compassion were more likely to
endorse intrinsic reasons for exercising (i.e., joy,

253
fun, and fulfillment) whereas those lower in selfcompassion endorsed more external
(e.g., to gain
positive regard from others, to avoid judgment) and
introjected motivations (e.g., to avoid feeling guilty
or ashamed). In an experimental study, Adams and
Leary (2007) found that a self-compassion prime
attenuated the disinhibited eating that typically
occurs after restrictive eaters break a dietary rule.
These two studies suggest that in non-clinical
samples, self-compassion might be associated with
the capacity for less disordered and more adaptive
eating and exercise habits.
Fear of Self-Compassion and Eating Disorders
Clinical anecdote suggests that patients with eating
disorders can often be resistant to treating themselves self-compassionately.
According to Liotti
(2010), compassion from both others and oneself
can be experienced as threatening for individuals
with emotional memories of having been abused,
neglected, and/or shamed by caregiver figures, histories that are common among
individuals with
eating disorders. There is now empirical evidence
that individuals differ in the extent to which they fear
self-compassion, and that fear is higher among
individuals vulnerable to psychopathology. Gilbert,
McEwan, Matos, and Rivis (2011) developed a selfreport measure designed to assess
the extent to
which individuals fear self-compassion out of worry
that, for example, they are undeserving of it, will
become dependent on it, lose their self-criticism,
become a less desirable person, and/or have a drop in
personal standards. In both clinical and non-clinical
samples, Gilbert and colleagues found that the
higher people’s fear of self-compassion, the lower
their level of trait self-compassion and the higher
their level of self-criticism, anxiety, and depression
(Gilbert, McEwan, Matos et al., 2011; Gilbert,
McEwan, Gibbons et al., 2011; Gilbert, 2012).
These findings add to the literature on self-compassion, and suggest that it may be
the combination of
low trait self-compassion and high fear of selfcompassion that is particularly
pathogenic.
The Current Study
The theoretical and empirical research reviewed
above suggests that a patient’s level and fear of selfcompassion may influence the
extent to which s/he is
able to overcome shame and eating disorder pathology. The overarching goal of the
present study was
therefore to test Gilbert’s theoretical model of shame,
self-compassion, and fear of self-compassion among
individuals with a clinical eating disorder admitted to
an intensive day hospital or inpatient eating disorders
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254

A. C. Kelly et al.

treatment program. We wanted to test this theory in a

transdiagnostic sample of eating disorder sufferers
given the growing interest in developing models and
interventions that apply across eating disorder diagnostic categories (Fairburn et
al., 2009; Fairburn,
Cooper, & Shafran, 2003).
In this preliminary investigation, our first objective
was to examine the baseline relationships among
self-compassion, fear of self-compassion, shame, and
eating disorder symptoms. We hypothesized that
these variables would be positively correlated with
each other, with the exception of self-compassion,
which would be negatively related to the other three
variables. Second, we sought to examine whether
patients’ baseline self-compassion and fear of selfcompassion would interact to
predict their subsequent changes in shame over 12 weeks. We
hypothesized that patients who had combinations
of higher trait self-compassion and lower fear of selfcompassion would show the
fastest reductions in
shame whereas those with combinations of lower
trait self-compassion and greater fear of selfcompassion would experience the
slowest reductions. Finally, we sought to investigate whether trait
self-compassion and fear of self-compassion would
interact to predict changes in eating disorder symptoms. We similarly hypothesized
that individuals with
combinations of lower self-compassion and higher
fear of self-compassion would have the slowest
improvements, whereas those with combinations
of higher self-compassion and lower fear of selfcompassion would have the greatest.

Method
Participants
In a pre-admission appointment occurring the week
before their treatment start date, patients were asked
by a clinical team member if they would like to
be contacted by a member of the research team to
find out more about a study on psychosocial functioning and eating disorders. Of
the 130 patients
admitted into treatment over our recruitment period,
97 agreed to be contacted. Of these, 18 patients did
not return our phone calls and 79 patients agreed to
meet with a research assistant within a few days of
their admission. Of these, 74 patients agreed to
participate upon learning more about the study and
reviewing the consent form. All participants gave
written informed consent.
Our 74 participants were primarily female (97%)
and ranged in age from 18 to 55 with a mean age of
27.5 years (SD #9.3). The ethnic makeup breakdown of the sample was 79.1%
Caucasian, 4.5% East
Asian, 1.5% South Asian, 2.9% African-Canadian,

10.5% Latino, and 1.5% mixed race. At the time of

their admission, all participants met Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for an
eating disorder based
on the Eating Disorder Examination (Fairburn &
Cooper, 1993). Within the sample, 29.2% of participants had the restricting subtype
of AN (AN-R),
18.5% had the binge-purge subtype of AN (AN-BP),
29.2% had BN, and 23.1% had an eating disorder not
otherwise specified (EDNOS). The admission BMI
in our final sample ranged from 12.5 to 35, with a
mean of 19.7 (SD #5.2). Twenty-two patients (31%)
were admitted to our inpatient unit and 52 (69%)
were admitted to our day hospital.
Treatment Programs
Our inpatient unit and day hospital are specialized
eating disorder treatment programs operated by an
interdisciplinary team. They both consist of intensive
group psychotherapy focused on medical stabilization, nutritional rehabilitation
through provision of
supervised meals, weight restoration in the case of
underweight patients, and eradication of binge
eating, purging, and excessive exercise. Behavior
change is a requirement of both programs: patients
adopt a new meal plan upon entry, and agree to
participate in grocery shopping, cooking, and restaurant outings. Although the
underlying orientation
of both programs is cognitive-behavioral, patients
attend a variety of manual-based groups on psychoeducation, relationships and
sexuality, expressive
arts, anxiety management, dialectical behavior
therapy, and cognitive-behavioral therapy. Selfcompassion is implicitly encouraged
in some of the
groups, but there is no group in either program
devoted to building self-compassion or addressing
fears of self-compassion.
Measures
Eating disorder symptoms. We assessed eating
disorder symptoms using the 36-item Eating Disorder Examination#Questionnaire (EDE-
Q; Fairburn & Beglin, 1994). The EDE-Q yields scores
on four subscales (Shape Concern, Weight Concern,
Eating Concern, and Dietary Restraint) which can
be combined into one global score. The EDE-Q has
been shown to have good internal consistency and
test-retest reliability (Luce & Crowther, 1999). In
our sample, the Cronbach’s alpha for the global scale
was .95, indicating strong internal consistency. The
sample mean at admission was 4.1 (SD #1.47)
confirming that this sample had clinically severe
eating disorder pathology (Mond, Hay, Rodgers, &
Owen, 2006).
Downloaded by [Laurentian University] at 23:21 07 December 2014

Self-compassion

255

Shame. Shame was assessed using the 25-item

Experiences of Shame Scale (ESS; Andrews, Qian, &
Valentine, 2002). The ESS asks participants to rate
the extent to which they experience various forms of
shame from 1 (not all) to 4 (very much). It yields
scores on three subscales of body, character, and
behavior shame as well as an overall score obtained
by taking the mean of all items. Sample items include
‘‘Have you felt ashamed of the sort of person you
are?’’ and ‘‘Have you tried to cover up or conceal
things you felt ashamed of having done?’’ Research
has shown the ESS to have good discriminant and
construct validity, as well as high test-retest reliability
(Andrews et al., 2002). The ESS demonstrated
strong internal consistency in our sample, with a
Cronbach’s alpha of .95. The mean ESS global score
in our sample was 3.15 (SD #.66) at baseline.

network of three academic hospitals in Toronto,

Canada. Participants were recruited from patients
admitted to the inpatient or day hospital treatment
program between the months of September 2010
and December 2011. In the consent meeting with
the research assistant, patients were asked to complete the first set of
questionnaires in that first
meeting and then again every 3 weeks during
treatment. These latter surveys were e-mailed to
them in the form of a link to a secure online survey
software. The baseline survey contained the SCSshort form, ESS, and FCS. The EDE-Q
was
administered as part of a separate intake package,
and baseline scores on this measure were thus
extracted from these packages. Surveys at all subsequent time points contained the
EDE-Q and ESS.

Self-compassion. Self-compassion was assessed

using the 12-item Self-Compassion Scale-Short
Form (SCS-SF; Raes, Pommier, Neff, & Van Gucht,
2011). It asks participants to rate their typical
reactions to distress and disappointment using a
5-point scale from 1 (almost never) to 5 (almost
always). Sample items include ‘‘I try to be kind and
patient towards those aspects of my personality I
don’t like,’’ ‘‘I try to see my failings as part of the
human condition,’’ and ‘‘When something painful
happens I try to take a balanced view of the
situation.’’ This scale has been found to show nearperfect correlations with the
full 26-item SelfCompassion Scale (SCS; Neff, 2003). In the current
study, it had a Cronbach’s alpha of .85, demonstrating good internal consistency,
and a mean at baseline
of 2.01 (SD #.68).

Results
Patterns of Missing Data

Fear of self-compassion. Fear of self-compassion was assessed with the relevant 15-
item section of
the Fear of Compassion Scale (Gilbert, McEwan,
Matos, et al., 2011). It asks participants to rate their
agreement with statements about expressing kindness and compassion towards oneself
using a scale of
0 (don’t agree at all) to 4 (completely agree). Sample
items include: ‘‘I feel that I don’t deserve to be kind
and forgiving to myself,’’ ‘‘I fear that if I am more self
compassionate I will become a weak person,’’ and
‘‘I fear that if I become too compassionate to myself
I will lose my self-criticism and my flaws will show.’’
This scale demonstrated strong internal consistency
with a Cronbach’s alpha of .95, and had a mean of
2.19 (SD #1.13) in our sample at baseline.

In the present analyses, we report on data for

74 patients who were admitted to one of our two
treatment programs. Responses to the EDE-Q at
Time 0 (i.e., baseline) were available for only 56 of
the 74 participants, with missing data accounted for
by 12 patients refusing to complete or simply not
returning the questionnaire, and six patients leaving
treatment before returning their responses. Responses to all other questionnaires
were available
for 72 participants at Time 0. At all subsequent
assessment points, the EDE-Q is administered in the
same survey as our other study measures. Data were
available for 49 participants at Time 1, 39 at Time 2,
30 at Time 3, and 22 at Time 4. Study drop-out
explained 42.0 to 47.6% of missing data at Times 1
through 4, with just under half of drop-outs occurring between Time 0 and Time 1.
At times 2 through
4, 22.0 to 28.6% of missing data was due to
premature discharge before receiving a full ‘‘dose’’
of treatment (due to either the patient choosing to
leave or the patient being asked to leave due to noncompliance or lack of
progress); 22 to 28% was due
to participants not yet having reached that particular
assessment point; and 2.3 to 6.3% was due to
participants having missed that particular assessment
(not explained by study drop-out or having yet to
reach that point in treatment). At Times 3 and 4
only, 4 to 4.7% of missing data was explained by
patients having already completed their recommended course of treatment.

Procedure

Analytic Strategy

The present study was approved by the Research

Ethics Board of the University Health Network, a

We conducted our primary analyses in SAS 9.3. To

test our hypotheses that self-compassion and fear of
Downloaded by [Laurentian University] at 23:21 07 December 2014

256

A. C. Kelly et al.

self-compassion would interact to predict changes in

eating disorder symptoms and shame over time, we
carried out two multilevel analyses using PROC
MIXED with maximum likelihood estimation. Multilevel modeling is the preferred
statistical approach
for longitudinal data that contain missing observations and assumes that data are
missing at random
(MAR), which is considered a reasonable assumption for many data sets containing
repeated measures
(Little, 1995). MAR means that the ‘‘missingness’’
of the data is thought to be unrelated to the
unobserved value(s), but may possibly be related to
the missing observation(s) through other variables
in the model for which observations are available
(Allison, 2002; McKnight, McKnight, Sidani, &
Figueredo, 2007). As per Hecker and Gibbons’s
(1997) recommendation, we tested pattern-mixture
models. We first grouped participants based on their
pattern of missing data by creating two-level (i.e.,
yes-no) categorical variables for the two primary
reasons for missing data in our sample, study dropout and premature treatment
discharge. We then
controlled for these categorical variables and their
interaction with time in both central analyses (predicting shame and EDE-Q) to
determine whether
they influenced outcome. No significant effects were
found, suggesting that there were no systematic
relationships between the outcome variables and
the mechanisms responsible for missing data.
Thus, our data appear to conform to the MAR
assumption. Having established that the MAR assumption was reasonable, subsequent
results are
reported without including the two variables representing patterns of missingness.
The dependent variables in our two central multilevel models were scores on the
EDE-Q and ESS
across the five assessment points. Each of our
multilevel models included a fixed- and randomeffects portion which respectively
model effects
whose values are thought to be constant and variable
across participants. The ‘‘betwithin’’ option was
used to compute the denominator degrees of freedom in the fixed effects model. We
initially included
a random intercept, a random effect for time, and an
autoregressive (AR[1]) structure for random error.
The random effect of Time was found to be nonsignificant, and was therefore dropped
from the
models reported here. Fixed effects included Time,
Program, baseline levels of the dependent variable,
and the latter’s interaction with Time. Each unit of
time represented roughly 3 weeks of treatment; a
negative effect for Time therefore indicated a
decrease in the dependent variable over the course
of treatment. Program was a dummy-coded categorical variable that represented the
treatment program
to which patients were admitted (i.e., day hospital or

inpatient). We initially included Program#Time as

a fixed effect in all models, but this interaction was
never a significant predictor and was thus removed.
All between-participant predictors were standardized
before testing our multilevel models to facilitate
interpretation of the results. The SAS programming
code for both central analyses are included in the
Appendix.
We first examined the unconditional (i.e., null)
model, ‘‘Model 1,’’ followed by a conditional model,
‘‘Model 2,’’ which contained Time as the sole
predictor, followed by a conditional model, ‘‘Model
3,’’ which included control variables, main
effects, and two-way interaction terms (i.e., SelfCompassion #Time, Fear of Self-
Compassion #
Time), followed finally by a conditional model,
‘‘Model 4,’’ which additionally included the
three-way interaction term of interest (i.e., SelfCompassion #Fear of Self-
Compassion #Time).
We then probed three-way interactions that emerged
as significant. First, we estimated simple slopes of
the dependent variable in questions as a function of
time for all four combinations of low (#1 SD) and
high (#1 SD) levels of self-compassion and fear of
self-compassion, with a negative slope indicating a
reduction in the dependent variable over time, and a
positive slope indicating an increase. Second, we
used contrasts to test our hypotheses that patients
with combinations of low self-compassion and high
fear of self-compassion would have the slowest rates
of change, and patients with combinations of high
self-compassion and low fear of self-compassion
would have the fastest rates of change. Finally, we
graphed our results by plotting estimated mean levels
of the dependent variable in question at each time
point for all four combinations of self-compassion
and fear of self-compassion.

Descriptive Statistics
Table I presents means and standard deviations for
both dependent variables, shame and eating disorder
symptoms, at each of our five assessment points.
Table I. Means and standard deviations of dependent variables
across assessment points
ESS total score

Time
Time
Time
Time
Time

0
1
2
3
4

(baseline)
(week 3)
(week 6)
(week 9)
(week 12)

EDE-Q global score

Mean

SD

Mean

SD

3.15
2.78
2.67
2.53
2.51

.66
.88
.87
.92
.86

72
49
39
30
22

4.12
3.78
3.51
3.24
3.22

1.47
1.53
1.55
1.39
1.40

56
49
39
30
22

Note. ESS # Experience of Shame Scale; EDE-Q # Eating

Disorders Examination Questionnaire.
Self-compassion
Table II. Zero-order correlations between study variables at
baseline

S-C
Fear of S-C
EDE-Q
Shame

S-C

Fear of S-C

#.63
#

EDE-Q
#.59
.67
#

b
b

Note. S-C # Self-Compassion; EDE-Q # Eating

Symptoms. All correlations significant at p B.001.
a
n # 69; b n # 52.

Shame
#.52
.66
.68
#

than 50% of their variance. In our sample, selfcompassion, fear of self-compassion,

shame, and
eating disorder pathology were therefore related
but distinguishable phenomena.

a
b

Disorder

1. Correlations between Study Variables at

Baseline

Downloaded by [Laurentian University] at 23:21 07 December 2014

257

Table II presents Pearson zero-order correlations

between study variables at baseline. Lower selfcompassion was associated with
greater fear of selfcompassion, greater pathology on the EDE-Q, and
higher shame. Fear of self-compassion was similarly
related to higher shame and more severe eating
disorder pathology. Consistent with past research,
shame and eating disorder symptom severity were
positively correlated. Although the associations
between study variables were modest to strong,
none of the correlations were higher than .68,
revealing that no two study variables shared more

2. Baseline Self-Compassion #Fear of SelfCompassion Predicting Change in Shame

over Time
Table III presents coefficients for all fixed effects in
the null and conditional models predicting shame.
As hypothesized and reported under Model 4,
the three-way interaction of self-compassion, fear
of self-compassion, and time was significant,
F(1, 116) # 7.10, p B.01. Fit indices additionally
supported Model 4 as being closest to the ‘‘true’’
model. Following Snijders and Bosker’s (1994)
formulas, we additionally found that Model 2
provided an increment of 24.8% within-persons
variance and 2.6% between-persons variance over
the null model, Model 3 provided respective increments of 10.9% and 81.2% over
Model 2, and
Model 4 provided respective increments of 3.6%
and 4.5% over Model 3. Because self-compassion
and fear of self-compassion at baseline were strongly

Table III. Fixed effect estimates, variance components, and model fit indices for
models predicting ESS shame scores
Model 1
Fixed effects
Intercept
Time
Program
Baseline Shame
Baseline Shame#Time
S-C
S-C#Time
Fear of S-C
Fear of S-C#Time
S-C#Fear of S-C
S-C#Fear of S-C #Time
Model fit indices
AIC
BIC
Variance components
Within-person s2
Within-person # R2D
Between-person t2
Between-person # R2D

2.93 (.09) ***

342.1
348.5
.1881 (.02) ***
.4589 (.09) ***

Model 2

3.09 (.09) ***

#.15 (.02) ***

303.4
312.0
.1415 (.02) ***
.2477
.4468 (.09) ***
.0264

Model 3

3.08
#.16
#.07
.60
#.07
#.05
#.00
#.03
.07
#.07

(.07)
(.02)
(.10)
(.07)
(.03)
(.07)
(.08)
(.13)
(.03)
(.05)

***
***
***
**

226.5
249.5
.1261 (.02) ***
.1088
.0841 (.02) ***
.8118

Model 4

3.12
#.21
#.06
.61
#.09
#.03
#.03
.04
.11
#.00
#.07

(.08)
(.34)
(.10)
(.07)
(.03)
(.07)
(.03)
(.08)
(.04)
(.06)
(.02)

***
***
***
***

*
**

221.3
246.4
.1217 (.01) ***
.0362
.0803 (.02) ***
.0451

* p B.05; ** p B.01; *** p B.001.

Note. S-C # Self-compassion; AIC # Akaike’s Information Criterion; BIC # Bayesian
Information Criterion. Model 1 is the null, or
unconditional, model containing no predictors. Model 2 is the conditional model
containing Time as the sole predictor, where one unit
of Time reflects 3 weeks of treatment from admission to week 12. Model 3 is the
conditional model containing all predictors except the
three-way interaction between self-compassion, fear of self-compassion, and time.
Finally, Model 4 is the conditional model containing all
predictors including the three-way interaction term. Coefficients for each model
are presented outside parentheses, with standard errors
presented inside. AIC and BIC are model fit indices with smaller numbers
representing better fit with the ‘‘true’’ underlying model.
s2 represents unexplained within-persons variance; t2 represents unexplained
between-persons variance, and # R2D, also known as
the pseudo-R2 (Singer, 1998; Snijders & Bosker, 1994; Tasca & Gallop, 2009), is the
percent increase in explainable within([s2 (unconditional) s2 (conditional)]/s2
(unconditional)) and between-persons variance ([t2 (unconditional) t2
(conditional)]/t2
(unconditional)) from Models 1 to 2, 2 to 3, and 3 to 4.
Downloaded by [Laurentian University] at 23:21 07 December 2014

258

A. C. Kelly et al.
average slope estimate of patients high in selfcompassion, t (116) #2.19, p B.05.

correlated with EDE-Q scores, we wanted to ensure

that the effects of Self-Compassion #Fear of SelfCompassion #Time remained when
controlling
for baseline eating disorder symptom severity. We
therefore entered baseline EDE-Q and baseline
EDE-Q #Time to the model. When we did this,
the three-way interaction remained significant,
F(1, 108) # 8.79, p B.01, revealing that the effects
of Self-Compassion #Fear of Self-Compassion on
changes in shame over time were not due to shared
variance with symptom severity.
Using our initial Model 4, without baseline
EDE-Q controlled, we computed simple slope estimates for all four combinations of
self-compassion
and fear of self-compassion (see Table IV). We then
graphically depicted these slopes by estimating and
plotting mean shame scores at each time point in
treatment for all four combinations (see Figure 1).
These estimates revealed that across levels of selfcompassion, patients with high
fear of self-compassion
had no significant changes in shame over time,
whereas those with low fear of self-compassion had
significant reductions. Planned contrasts additionally
revealed that the slope estimate for patients with
lower self-compassion and higher fear of selfcompassion differed from the average
of the other
three slope estimates, revealing that this combination
was associated with a slower rate of shame reduction
than the average rate of patients who had other
combinations of self-compassion and fear of selfcompassion. Contrary to hypotheses,
the estimated
rate of change of patients with high self-compassion
and low fear of self-compassion did not differ
significantly from that of other patients. Post-hoc
contrasts additionally indicated that the slope estimate for patients with low
self-compassion and high
fear of self-compassion differed from that of patients
with low self-compassion and low fear of selfcompassion, t (116) #2.29, p B.05, and
from the

3. Baseline Self-Compassion #Fear of

Self-Compassion Predicting Changes in
Eating Disorder Symptoms over Time
Table V presents coefficients for all fixed effects in
the null and conditional models predicting eating
disorder symptoms. As hypothesized and seen under
Model 4, the three-way interaction term of SelfCompassion #Fear of Self-Compassion
#Time was
a significant predictor, F(1, 112) #10.18, p B.001
of changes in eating disorder symptoms. Fit indices
additionally revealed that Model 4 is closest to the
‘‘true’’ model. We further found that Model 2
explained an additional 35% and 2.7% of modeled
within- and between-persons variance over Model 1,
Model 3 added 14.4% and 93% to the explainable
within- and between-persons variance over Model 2,
and Model 4 added an additional 11.4% and 4.1%
over Model 3.
Simple slope estimates are presented in Table IV
for all four combinations of low and high selfcompassion and fear of self-
compassion. For each
of these combinations, Figure 2 additionally displays
estimated mean EDE-Q global scores at each
assessment point. As evident from both the table
and graph, the eating disorder symptoms of patients
with combinations of low self-compassion and high
fear of self-compassion did not change over time,
whereas patients with each of the other three
combinations of self-compassion and fear of selfcompassion had significant
reductions. Planned
contrasts additionally revealed that the EDE-Q slope
estimate for the former group of patients differed
from the average of the other three slope estimates,
in support of our hypotheses. Contrary to our
hypotheses, the slope estimate of patients with
combinations of high self-compassion and low fear

Table IV. Slope estimates and contrasts for all combinations of high and low self-
compassion and fear of self-compassion predicting
changes in shame and eating disorder symptoms
Rate of change (slope) in shame

Combination of S-C and fear of S-C

Low S-C, low fear of S-C
Low S-C, high fear of S-C
High S-C, low fear of S-C
High S-C, high fear of S-C
Contrast of slope estimates
Low S-C, high fear of S-C vs. average of other three slopes
High S-C, Low Fear of S-C vs. average of other three slopes

Rate of change (slope) in EDE-Q

SE

pr

SE

pr

#.38
.07
#.34
#.18

.13
.11
.07
.13

#2.93
.66
#4.57
#1.37

.004
.510
B.001
.174

#.42
.10
#.43
#.57

.18
.16
.11
.18

#2.34
.66
#4.04
#3.09

.021
.509
B.001
.003

.29
.04

.13
.17

2.23
.25

.028
.803

.51
.31

.18
.24

2.91
1.29
.004
.198

Note. S-C # Self-compassion. n # 64 for shame analyses and n # 54 for EDE-Q

analyses with slope estimates and contrasts using 116 and
112 degrees of freedom respectively. Slope estimates are rates of change in the
dependent variable for every one unit difference in the betweenpersons predictor
variables. In our analyses, one unit of Time reflects 3 weeks of treatment
beginning at admission and ending at week 12
Self-compassion

259

Table V. Fixed effect estimates, variance components, and model fit indices for
models predicting EDE-Q global scores

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Model 1
Fixed effects
Intercept
Time
Program
Baseline EDE-Q
Baseline EDE-Q#Time
S-C
S-C#Time
Fear of S-C
Fear of S-C#Time
S-C#Fear of S-C
S-C#Fear of S-C #Time
Model fit indices
AIC
BIC
Variance components
Within-person s2
Within-person # R2D
Between-person t2
Between-person # R2D

3.75 (.18) ***

Model 2

4.05 (.19) ***

#.23 (.03) ***

501.6
508.1

464.2
472.8

.4062 (.05) ***

.3008 (.05) ***

.3504
1.8283 (.39) ***
.0271

1.8793 (.37) ***

Model 3

3.96
#.24
#.02
1.35
#.15
#.22
.04
#.03
.12
.12

(.11)
(.03)
(.14)
(.11)
(.05)
(.11)
(.04)
(.13)
(.05)
(.05)

***
***
***
***
*

*
***

319.8
341.3
.2575 (.03) ***
.1439
.1281 (.04) ***
.9299

Model 4

4.07
#.33
#.01
1.40
#.19
#.15
#.02
#.10
.19
#.02
#.15

(.11)
(.04)
(.13)
(.10)
(.04)
(.10)
(.04)
(.12)
(.04)
(.08)
(.03)
***
***
***
***

***
***

303.7
327.1
.2281 (.03) ***
.1141
.1228 (.04) ***
.0414

* p B.05; ** p B.01; *** p B.001.

Note. S-C # Self-compassion; AIC # Akaike’s Information Criterion; BIC # Bayesian
Information Criterion. Model 1 is the null, or
unconditional, model containing no predictors. Model 2 is the conditional model
containing Time as the sole predictor, where one unit of
Time reflects 3 weeks of treatment from admission to week 12. Model 3 is the
conditional model containing all predictors except the threeway interaction between
self-compassion, fear of self-compassion, and time. Finally, Model 4 is the
conditional model containing all
predictors including the three-way interaction term. Coefficients for each model
are presented outside parentheses, with standard errors
presented inside. AIC and BIC are model fit indices with smaller numbers
representing better fit with the ‘‘true’’ underlying model. s2
represents unexplained within-persons variance; t2 represents unexplained between-
persons variance, and # R2D, also known as the
pseudo-R2, is the percent increase in explainable within- and between-persons
variance from Models 1 to 2, 2 to 3, and 3 to 4. Formulas are
the same as those used in Table III.

Figure 1. Self-Compassion #Fear of Self-Compassion #Time predicts rate of change in

ESS. Mean estimates of the dependent variable
for all combinations of high (1 SD above the sample mean) and low (1 SD below the
mean) of self-compassion (S-C) and fear of selfcompassion (fear of S-C) at each
time point, where 0 is baseline and each unit of time reflects roughly three weeks
of treatment. n # 64.
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260

A. C. Kelly et al.

Figure 2. Self-Compassion #Fear of Self-Compassion #Time predicts rate of change in

EDE-Q global. Mean estimates of the dependent
variable for all combinations of high (1 SD above the sample mean) and low (1 SD
below the mean) of self-compassion (S-C) and fear of
self-compassion (fear of S-C) at each time point, where 0 is baseline and each unit
of time reflects roughly three weeks of treatment. n # 54.

of self-compassion did not differ from the average of

the other three. These findings reveal that patients
who were both lower in self-compassion and more
fearful of becoming self-compassionate had a significantly poorer treatment
response than patients
with other combinations of baseline self-compassion
and fear of self-compassion. Additional post-hoc
contrasts indicated that among patients low in selfcompassion, slope estimates
differed at a trend-level
between those low and high in fear of self-compassion, t (112) #1.94, p #.06, and
this difference was
larger than that among patients high in self-compassion, t (112) # 2.43, p B.05.

Discussion
To our knowledge, the present study is the first
to investigate self-compassion and fear of selfcompassion in eating disorder
patients, and the
first to examine changes in shame over the course
of eating disorders treatment. We found, first, that
among patients admitted to day hospital and inpatient treatment, higher self-
compassion at baseline
was associated with lower shame and less severe
eating disorder pathology, whereas higher fear of
self-compassion was associated with higher shame
and more severe eating disorder pathology. Second,
baseline self-compassion and fear of self-compassion
interacted to predict changes in shame over 12

weeks of treatment. Patients who had lower selfcompassion combined with higher fear
of selfcompassion had no significant subsequent change
in shame, and this outcome was significantly poorer
than that of other patients. Third, baseline fear of
self-compassion interacted with trait self-compassion
to predict changes in eating disorder symptoms over
12 weeks. Those patients with both lower selfcompassion and higher fear of self-
compassion had
no significant changes in eating disorder symptoms
over time, and this outcome differed from the
average of other patients. In addition, among
patients higher in trait self-compassion, eating
disorder symptoms decreased independent of their
fear of self-compassion, whereas among those
lower in baseline self-compassion symptoms decreased only if patients’ fear of
self-compassion
was relatively low. These results suggest that fear
of self-compassion, especially in the presence of
low dispositional self-compassion, might impede
response to mainstream eating disorders treatment.

Baseline Correlations between SelfCompassion, Fear of Self-Compassion,

Shame, and Eating Disorder Symptoms
At baseline, self-compassion and fear of self-compassion were negatively correlated
in our sample, but
shared less than 40% of their variance, revealing that
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Self-compassion
they are related yet distinguishable constructs in a
clinical sample of eating disorder sufferers. Their
correlation nevertheless suggests that when targeting
patients’ low self-compassion, therapists should be
sensitive to the additional fear of self-compassion
these patients are likely to have. Both of these
variables were associated with shame, as measured
by the ESS, and eating disorder pathology, as
measured by the EDE-Q, in expected ways: shame
and eating disorder pathology were more severe the
higher patients’ fear of self-compassion and the
lower their dispositional self-compassion. Consistent
with Goss and Gilbert’s (2002) theoretical model of
eating disorders, and in line with past empirical
studies, we also found a strong correlation between
feelings of shame and eating disorder symptoms
(Keith, Gillanders, & Simpson, 2009; Troop et al.,
2008).

Prediction of Changes in Shame

Baseline fear of self-compassion interacted with
baseline self-compassion to predict changes in shame
over 12 weeks of treatment. Across levels of trait selfcompassion, lower fear of
self-compassion was
associated with greater decreases in shame; higher
fear of self-compassion, however, was associated
with negligible changes in shame and this was
especially true for patients lower in trait self-compassion. These results remained
even when we controlled for patients’ baseline scores on the EDE-Q,
revealing that the effects of the Self-Compassion #Fear of Self-Compassion #Time
interaction
on shame were not accounted for by the variance
shared between these variables and the EDE-Q.
Results are consistent with Gilbert’s (2005, 2009)
theoretical model, which posits that compassion*
from self and others*is crucial for the alleviation
of shame. Interestingly, our results suggest that
among eating disorder patients, baseline attitudes
toward self-compassion may be more important than
actual tendencies to be self-compassionate in predicting decreases in shame
experiences over the
course of treatment.
Although our analyses do not speak to mechanisms of change, one might imagine that
patients who
were more fearful of self-compassion would have
been more reluctant to acknowledge and share their
feelings with co-patients and therapists during treatment. As such, it may have
been more difficult for
them to elicit and receive the compassion from
others likely to not only alleviate shame but also
instill in them memories of warmth conducive to
subsequent self-compassion (Gilbert, 2005; Irons,
Gilbert, Baldwin, Bacchus, & Palmer, 2006).

261
Indeed, Neff (2003) found that people who are
lower in self-compassion tend to be more selfconscious and less likely to try and
make themselves
feel better after a negative experience.

Prediction of Changes in Eating Disorder

Symptoms
We found that baseline self-compassion and fear of
self-compassion interacted to predict changes on the
EDE-Q over time. Patients lower in self-compassion
and higher in fear of self-compassion had next to no
change in eating disorder symptoms over 12 weeks
of treatment, and this non-response differed from
the average response of other patients. Fear of selfcompassion appeared especially
harmful among
patients low in self-compassion. Patients who were
higher in trait self-compassion had significant decreases in eating disorder
symptoms across levels of
self-compassion fear, but among patients lower in
self-compassion, symptoms decreased only among
those individuals who were less afraid of becoming
self-compassionate. These findings emerged controlling for baseline symptom
severity, a robust predictor
of eating disorder treatment outcome. Findings
therefore suggest that the combination of low trait
self-compassion and high fear of self-compassion may
prevent eating disorder patients from responding to
intensive group-based cognitive-behavioral treatment.
Being asked to eat a wide range of avoided foods
without compensating through exercise, fasting, or
purging could be seen as adopting a caring, kind
attitude towards oneself and one’s body. Although
this process is difficult for anyone with an eating
disorder, it may be all the more difficult for patients
who had have little self-compassion and who believe
that becoming self-compassionate will lead to negative consequences. At times of
distress, individuals
low in self-compassion are unable to take a balanced
view of the situation, ruminating on and feeling
alone in their negative emotions, and judging themselves critically rather than
showing themselves
kindness (Neff, 2003). Individuals who fear selfcompassion additionally believe
that reacting to their
distress in a more compassionate way would make
them weak, expose their flaws, and lead to a drop in
personal standards (Gilbert, McEwan, Matos et al.,
2011). When confronted with the fear and shame
frequently triggered by treatment norms, such as
eating more and gaining weight, patients who are
fearful and low in self-compassion may feel stuck: the
only tools they have to manage these emotions are
the ones they are being asked to give up. They might
therefore cling to their eating disorder for emotion
regulation, and/or as a way to punish themselves for
262

A. C. Kelly et al.

the difficulties they are enduring, hypotheses worth

exploring in future research. Resistance to eliciting
support from others might also help to explain the
poor response of patients with high fear of selfcompassion and low trait self-
compassion. These
proffered explanations require further testing.

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Clinical Implications
How can we better intervene with patients who are
so afraid of and unused to self-compassion that they
are unable to benefit from mainstream eating disorder treatment? Currently,
treatment manuals for
eating disorders suggest ways to help self-critical,
perfectionistic patients, but make little mention of
how to address the fear of self-compassion likely to
be present among these vulnerable individuals.
Gilbert (2005, 2009) developed compassion-focused
therapy (CFT) to help self-critical, shame-prone
individuals understand and overcome their fear of
self-compassion. In this approach, therapists work
with patients from a biopsychosocial model to
identify the factors in their development that may
have led them to develop in ways that may have
made the processing of compassion not only difficult
but frightening. Gilbert suggests that patients can
come to feel ashamed of their own defensiveness to
compassion, making it important for therapists to
normalize their resistance in light of their past
experiences. In some ways, this approach seeks to
help patients develop self-compassion for the fact
that they are afraid of self-compassion. Our results
suggest that there might be value to integrating a
CFT approach early in therapy for a subset of
patients. Future research would benefit from testing
this hypothesis and investigating how best to incorporate these interventions into
traditional groupbased treatments for eating disorders.

Limitations and Future Research

The first limitation of our study is that data collection is ongoing, meaning that
the current results
are preliminary. Once data collection is complete
and a more desirable sample size is achieved, it will
be interesting to build on our current analyses by
examining different outcome variables*for example,
whether participants who are fearful and lower in
self-compassion are more likely to drop out of
treatment prematurely and/or more likely to relapse.
Second, the findings are correlational in nature,
meaning that we are unable to determine whether
fear of self-compassion causes poor treatment outcomes among low self-compassion
patients. In a
future experimental study, it would be interesting to
examine interventions designed to increase selfcompassion and reduce fear of self-
compassion
among individuals with eating disorders to test their
impact on eating disorder symptomatology and
shame.
Third, these preliminary analyses do not speak to
the mechanisms by which fear of self-compassion
and self-compassion interact to predict treatment
response. A test of theoretically relevant mediators in
subsequent research would help to explain the
associations we observed in the present analyses.
Finally, to subject Goss and Gilbert’s (2002)
model to more rigorous empirical testing, an important next step once data
collection is complete
will be to examine whether changes in shame are
longitudinally coupled with changes in eating disorder symptoms over the course of
treatment.

Conclusions
The present research offers preliminary evidence
that self-compassion and fear of self-compassion
influence response to intensive eating disorder treatment in terms of both
vulnerability (i.e., shame) and
symptomatology. Predictors of treatment outcome
examined to date have largely been related to eating
disorder pathology and other Axis I and II disorders.
Although there has been some research on the
personality traits associated with vulnerability to an
eating disorder, this is the first study to our knowledge on self-compassion and
fear of self-compassion
in a clinical eating disorder sample. The poorer outcomes we observed for patients
who are fearful of
and low in self-compassion point to an important set
of patient variables that require future attention in
eating disorder research, assessment, and treatment.
Acknowledgements
This article was funded by the Ontario Mental
Health Foundation.
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Appendix A
SAS Code for Multilevel Model Predicting Changes in Shame and Eating Disorder
Symptoms
PROC MIXED NOCLPRINT METHOD #ML COVTEST;
CLASS PROGRAM ID; WHERE TIME B5;
MODEL ESS #TIME PROGRAM BLSHAME BLSHAME*TIME
BLFEARCOMP_SELF BLFEARCOMP_SELF*TIME
BLCOMPASS BLCOMPASS*TIME BLCOMPASS*BLFEARCOMP_SELF
BLCOMPASS*BLFEARCOMP_SELF*TIME
/S DDFM #BETWITHIN;
RANDOM INTERCEPT/TYPE #UN SUBJECT #ID;
RUN;
PROC MIXED NOCLPRINT METHOD #ML COVTEST;
CLASS PROGRAM ID; WHERE TIME B5;
MODEL EDEQ #TIME PROGRAM BLEDEQ BLEDEQ*TIME
BLFEARCOMP_SELF BLFEARCOMP_SELF*TIME
BLCOMPASS BLCOMPASS*TIME
BLCOMPASS*BLFEARCOMP_SELF
BLCOMPASS*BLFEARCOMP_SELF*TIME
/S DDFM #BETWITHIN;
RANDOM INTERCEPT/TYPE #UN SUBJECT #ID;
RUN;