Compassion, stories and eating disorders
A compassionate approach to eating disorders and helping children learn about body image and healthy relationships with food.
After a series of nature based articles, a return to compassion based research in this article, which considers the relationship of eating disorders, emotions and body image, along with reviewing recent studies of treatment approaches and a story telling approach to support children.
Last November the National Health Service in England published the latest edition of the Mental Health of Children and Young People in England 2023 report. For the first time since 2017 data on eating disorders within children and young people was captured, which reveals some concerning figures.
In 2017 0.8% of respondents aged 17 to 19-years-old reported an eating disorder. In the 2023 report that has risen to 12.5%. There were increases in both young men and women, with the sharpest rise in young women from 1.6% in 2017 to 20.8% in 2023. In the age group below this, 11 to 16-year-olds, the 2023 level was up to 2.6%, from the 2017 level of 0.5. Girls were again more affected, with 4.3% compared to 1% of boys.
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It appears hard to get good data on the overall level of eating disorders within the UK. The UK’s eating disorder charity Beat estimates that 1.25 million people in the UK have an eating disorder, although this estimate is based on a number of studies and extrapolation. Coupled with the data from NHS England though it suggests eating disorders are an increasing issue, especially within children and young people.
It is worth defining what is meant by eating disorders. Based on the latest diagnostic definition, the American Psychiatric Association describes them as “behavioral conditions characterized by severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions. They can be very serious conditions affecting physical, psychological and social function. Types of eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder, other specified feeding and eating disorder, pica and rumination disorder.”
Eating disorders appear to have a close relationship with body image, which Rachel Rodgers and others highlight in a 2023 article is a global mental health issue, with high levels of body image concern prevalent in most societies. Levels are especially high within wealthy English speaking countries, notably the USA, and in affluent Asian countries. Research across many countries and cultures suggests that a common key factor towards poor body image is individuals feeling pressure as a result of depictions of “ideal bodies” within the media and social discourse. Concerns about body image may influence how someone evaluates their own body, the level of dissatisfaction they have towards their appearance, while supporting negative attitudes towards their self-identity. Negative emotions, such as shame and low perception of self, coupled with poor emotional regulation can lead to maladaptive behaviours such as disordered eating. Eating disorders may lead to physical health risks and reduced wellbeing, including being very underweight or obese. That said, as Natasha and Nathan Ramaswamy 2023 commentary highlights, it is worth stressing that there can be too much focus on weight or Body Mass Index (BMI), and many people with an eating disorder are within healthy weight or BMI ranges.
Adding compassion
Within the UK talking therapies, including Family Therapy and a version of Cognitive Behavioural Therapy for eating disorders (CBT-ED), are recommended as part of treatment programmes by the National Institute for Health and Care Excellence. A number of reviews, for example Leslie Citrome’s 2021 overview of treatment approaches for Binge Eating Disorder (BED), have highlighted a moderate effectiveness from CBT. CBT has a focus on addressing maladaptive cognition and thought patterns, and so may not fully address poor emotional regulation which may be connected to eating disorders. CBT’s effectiveness with individuals who have experienced childhood traumatic events may also be reduced. A potential alternative is Compassion Focused Therapy (CFT), with a CFT programme developed by Ken Gross and Steven Allan (2010) for the treatment of eating disorders (CFT-E). This was developed with the hypothesis that CFT may provide greater help with emotional regulation while addressing psychological aspects such as shame and self-criticism. Two recent studies have considered the effectiveness of CFT in treating eating disorders.
Addressing body weight shame
Alicia Carter and colleagues at the University of Queensland 2023 paper details a study which used a Randomised Control Trial (RCT) design to assess a CFT based programme designed to help obese individuals, whose personal body image resulted in them feeling ashamed and inferior to others, along with high levels of self-criticism. The RCT used a 12 session CFT programme delivered in a group format in comparison to a “waitlist” control group, with measurement points at pre and post intervention plus two follow-up points at 3 and 6 months. The overall sample was 55 adults aged between 19 and 70 years old (average age 46), of whom 51 were female. A number of measures were taken, including assessing body image and external shame, self-compassion, emotional regulation and mood, along with Heart Rate Variability (HRV). The control group included 27 participants while the CFT group was made up of 28 participants, which reduced slightly at the two follow-up measurement points.
Overall the CFT programme indicated significant reductions in levels of internal and external shame, with increased self-compassion, self-reassurance and perspective-taking at the end of the intervention which was sustained at the follow-up points. Benefits to mood were found, with 60% of the CFT group improving on the depression measure. The HRV measure used to assess parasympathetic nervous system activity which is linked to restoration and reduced negative affect, showed no change from the intervention.
One key limitation of the study is the use of a “waitlist” group, which effectively means the participants in the control condition of the RCT are waiting to receive treatment. In that group 25% of the participants also had an improvement on depression scores, reflecting an issue with using waitlists, as individuals may start to look for other self-help or find things that are helpful outside of the study’s control. Additionally the study sample is of a small size and consists mainly of female participants.
However, the study results do support other studies of CFT within eating disorder treatment, where it has helped to significantly address negative attitudes towards how participants saw themselves, through reduced body weight shame and self-criticism, coupled with increased self-compassion and self-reassurance.
Comparing interventions
One way to address the limitation of using a “waitlist” group within a RCT study is to use a comparison therapeutic approach as a control condition. KariAnne Vrabel and colleagues 2024 paper details a Norwegian study which employed a RCT design to consider the effectiveness of CBT-ED and CFT-E upon the treatment of individuals with different eating disorders, except for Binge Eating Disorder (BED).
During a period across 2015 to 2018, 130 participants were randomly assigned through blind allocation to either a CBT group (65 participants at start, reducing to 59 at the end) or CFT group (65 participants at start, reducing to 55 at the end). Half of the participants had experienced childhood trauma. The treatment plan ran over 13 weeks and was conducted in groups of 8, being a mixture of group and individual therapy sessions. The average age of the participants was 31 years old and 98% were female. Standard measures of eating disorder, trauma, mental health and interpersonal relationships were used. The results found that there was no significant difference between CFT and CBT, both had a large improvement effect on the eating disorders across the participants, which was sustained at follow-up. CFT appeared to be more beneficial than CBT at follow-up for those participants who had experienced childhood trauma. The attrition rates during the treatment period were relatively low, with slightly more within the CFT condition. A limitation of the study is that it did not distinguish between specific eating disorders, which further RCTs could address and the adult participants were predominately female.
Other papers published in 2023 relating to the same study indicated that both the CBT and CFT treatments had increased participants self-compassion, while greater improvements in participants mood scores were found within the CFT group, suggestive of benefits to emotional regulation. So across these papers the study suggests that CFT appears at least equal to the current standard of CBT, with some specific aspects benefiting more from a compassion based intervention.
Telling stories
Both of those studies involved adult participants and there is an issue that research into effectiveness of treatment cannot address. Reported analysis of NHS data by the Children’s Commissioner for England highlights that treatment targets for children and young people are not being met in around a fifth of cases, with some urgent cases reported as waiting more than twelve weeks to start treatment compared to the target of one week.
Working with the First Steps Eating Disorder charity, a team from the University of Derby developed a storybook for 6 to 11-years-old to help facilitate discussions around disordered eating behaviours for use within schools and at home. A very recently published (pre-print) paper by Dominic Petronzi and colleagues (2024) provides details of a qualitative study relating to the storybook. The authors highlight the 6 to 11-year-old age group may not be able to access appropriate help, as often under the age of 12-years-old children are referred to health initiatives such as weight loss programmes rather than eating disorder services. The Noodles Healthy Eating Heroics storybook uses rhyming verse to tell the story of Mason, a young boy with concerns about his body image and eating behaviours, who is helped by his family and friends towards a healthy, balanced relationship with food. Noodles, the family dog, plays the role of an observer to help readers engage with the story. Reading is seen as a non-food related activity which parents can be involved with and the book was launched to tie with the 2021 World Book Day.
The qualitative study gathered data from 16 participants, including educators and parents, with the analysis identifying four themes around the use of a storybook to help young children. Firstly, teachers and parents both found it a helpful resource to help talking about what can be a difficult topic and they appreciated it helped with their own perceptions towards food, as well as addressing concerns that social pressures may be having on children’s body image. Secondly the format of a storybook allowed the topics to be handled in a natural way, with the characters helping build empathic responses and a sense of hope. The participants felt it was important that the main character was a boy, given some incorrect perceptions around eating disorders being an issue that affects only girls, and the story was a supportive resource to aid discussions both within educational settings and at home. Thirdly, the participants welcomed the story reflecting concerns of social comparison upon children’s body image and managing emotional responses to related social media posts. The last theme covered the potential development of the storybook, with suggestions around follow-on stories and including other social aspects which influence children’s body image, such as pressures that may occur within certain sports. Suggestions for supportive activities linked to the story were also provided.
While a small scale study the feedback and reception to the storybook suggests such resources can be a powerful tool to support young children to talk about their concerns while raising awareness in a supportive manner, which may perhaps reduce an eating disorder developing to the extent that clinical interventions are required.
To lose confidence in one’s body is to lose confidence in oneself.
Simone de Beauvoir’s words feel appropriate to underlying emotional and self-perception issues which may contribute to eating disorders, where shame and self-criticism can affect self-identity. Disordered eating is a growing concern globally with indications that it is an increasing issue within children and young people, which the availability of support and treatment may not be keeping pace with. Helping children at an early age during which their self-identity is developing to navigate social pressures they encounter by fostering emotional regulation skills and providing information around healthy eating patterns may be helpful. Engaging resources such as storybooks offer a positive contribution towards that. Understanding the elements that provide the best long-term benefits to individuals of therapeutic interventions such as CBT and CFT, which can be costly and take time to deliver, is a crucial step for treatment.
Even more crucial is enabling support and treatment to be quickly accessed by those in need of help to manage and recover from eating disorders.
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References
Carter, A., Steindl, S. R., Parker, S., Gilbert, P., & Kirby, J. N. (2023). Compassion-Focused Therapy to reduce body weight shame for individuals with obesity: A randomized controlled trial. Behavior Therapy, 54(5), 747-764. https://doi.org/10.1016/j.beth.2023.02.001
Citrome, L. (2021). Binge eating disorder: a psychiatrist's commentary on clinical considerations. Clinical Therapeutics, 43(1), 7-1 https://doi.org/10.1016/j.clinthera.2020.10.013
Goss, K., & Allan, S. (2010). Compassion focused therapy for eating disorders. International Journal of Cognitive Therapy, 3(2), 141-158. https://doi.org/10.1521/ijct.2010.3.2.141
Petronzi, D., Scott, C., Sharpe, E. E., & Petronzi, R. (2024). Parent, educator, and practitioner perceptions of a storybook approach to raise awareness of unhealthy attitudes towards and behaviours around eating in children. https://doi.org/10.31234/osf.io/pmn3d
Ramaswamy, N., & Ramaswamy, N. (2023). Overreliance on BMI and delayed care for patients with higher BMI and disordered eating. AMA Journal of Ethics, 25(7), 540-544. https://journalofethics.ama-assn.org/article/overreliance-bmi-and-delayed-care-patients-higher-bmi-and-disordered-eating/2023-07
Rodgers RF, Laveway K, Campos P, de Carvalho PHB (2023). Body image as a global mental health concern. Cambridge Prisms: Global Mental Health, 10, e9, 1–8 https://doi.org/10.1017/gmh.2023.2
Vrabel, K. R., Waller, G., Goss, K., Wampold, B., Kopland, M., & Hoffart, A. (2024). Cognitive behavioral therapy versus compassion focused therapy for adult patients with eating disorders with and without childhood trauma: A randomized controlled trial in an intensive treatment setting. Behaviour Research and Therapy, 174, 104480. https://doi.org/10.1016/j.brat.2024.104480
This is really interesting, Chris. The book aimed at children isn’t one I’ve heard of, I’ll look it up. I know the Karen Treisman therapeutic story books can be really helpful for children who have experienced trauma and can see their struggle reflected in a character.