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1 MALADAPTIVE PERFECTIONISM AND DISORD ERED EATING IN COLLEGE WOMEN: THE MEDIATING ROLE OF SELF-COMPASSION By JENNIFER STUART A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2009
2 2009 Jennifer Stuart
3 To my grandparents, for teaching me the value of compassion
4 ACKNOWLEDGMENTS I would first like to acknowledge m y committee members for their guidance, mentorship, and support during the past several y ears. Each contributed valuable expertise to this research. I would like to thank Dr. Scott Mi ller for his steady presence a nd insight, Dr. Mary Fukuyama for her experience and perspective, a nd Dr. Wayne Griffin for continually challenging me to grow as a scholar and as a person. I woul d especially like to thank my ch air, Dr. Ken Rice, for patiently sticking with me through the many iterations of this project, offering guidance when needed, and tempering my anxiety with realism and humor. His mentorship helped me to push through when things seemed not to make sense, and helped me discover my own voice as a researcher along the way. I would also like to thank the staff members at both the Univ ersity of Florida Counseling Center and Arizona State University Counseli ng and Consultation who helped with the design and implementation of this project. The many on e-on-one meetings helped me refine my ideas and put them into practice. This research coul d not have been completed without the support of these agencies and individuals. Finally, I offer my sincere thanks to my fam ily who never doubted that I could do this, and the many wonderful friends who kept me grounded through the process. In countless ways and always at the perfect time, th ese individuals brought me back to the present moment and reminded me of what really matters. Thei r love is what makes this worthwhile.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ............................................................................................................... 4LIST OF TABLES ...........................................................................................................................7LIST OF FIGURES .........................................................................................................................8ABSTRACT ...................................................................................................................... ...............9 CHAP TER 1 INTRODUCTION .................................................................................................................. 112 LITERATURE REVIEW .......................................................................................................17Eating Disorders Overview .....................................................................................................17Eating Disorders on College Campuses .................................................................................18Eating Disorders Prevention ...................................................................................................18Eating Disorders and Perfectionism ....................................................................................... 21Perfectionism and Eating Di sorders Intervention ................................................................... 24Perfectionism, Eating Disorders, and the Self ....................................................................25Perspectives from Buddhist Psychology ................................................................................ 28Self-Compassion ............................................................................................................... ......29Mindfulness and Psychotherapy .............................................................................................31Mindfulness and Self-Compassion .........................................................................................35Mindfulness and Disordered Eating .......................................................................................37Present Research .....................................................................................................................41Rationale for Study 1 .......................................................................................................42Hypotheses for Study 1 ................................................................................................... 42Rationale for Study 2 .......................................................................................................43Hypothesis for Part 2 .......................................................................................................443 METHODS AND MATERIALS ........................................................................................... 45Study 1 ....................................................................................................................................45Participants .................................................................................................................. ....45Measures ...................................................................................................................... ....46Procedure ..................................................................................................................... ....51Study 2 ....................................................................................................................................52Participants .................................................................................................................. ....52Procedure ..................................................................................................................... ....53Description of self-compassion workshop ...............................................................53Advertising and recruitment ..................................................................................... 54Data collection ..........................................................................................................54
6 4 RESULTS ....................................................................................................................... ........56Study 1 ....................................................................................................................................56Descriptive Statistics an d Preliminary Analyses ............................................................. 56Self-Compassion as Mediator ..........................................................................................59Maladaptive perfectionism, self-c ompassion, and disordered eating ...................... 60Moderated mediation: Gender .................................................................................. 60Moderated mediation: B ody image investment ....................................................... 62Exploratory Analyses: Self-C ompassion vs. Self-Esteem ............................................... 63Multiple mediation ...................................................................................................63Moderated mediation: self-esteem as moderator ..................................................... 64Study 2 ....................................................................................................................................65Descriptive Statistics an d Preliminary Analyses ............................................................. 65Treatment Effects ............................................................................................................ 665 DISCUSSION .................................................................................................................... .....74Study 1 ....................................................................................................................................74Clinical Implications ....................................................................................................... 77Limitations and Future Directions ................................................................................... 79Study 2 ....................................................................................................................................82Implications .................................................................................................................. ...83Limitations and Future Directions ................................................................................... 85Conclusion .................................................................................................................... ..........87APPENDIX A STUDY 1 INFORMED CONSENT .......................................................................................88B STUDY 1 DEMOGRAPHIC QUESTIONNAIRE ................................................................ 90C STUDY 2 INFORMED CONSENT .....................................................................................101D STUDY 2 DEMOGRAPHIC QUESTIONNAIRE .............................................................. 103E SELF-COMPASSION WORKSHOP RECRUITMENT FLI ER .........................................105F SELF-COMPASSION WRITING EXERCISE INSTRUCTIONS...................................... 106G SELF COMPASSION MEDI TATION INSTRUCTIONS ..................................................107H LIST OF DEFINITIONS AND TERMS ..............................................................................108LIST OF REFERENCES .............................................................................................................110BIOGRAPHICAL SKETCH .......................................................................................................123
7 LIST OF TABLES Table page 4-1 Internal Consistency, Means, and Standard Deviations of Study 1 Variables ...................674-2 Pearson Correlations Between Study 1 Variables .............................................................684-3 Self-Compassion as Mediator Between Mindfulness and Disordered Eating ...................694-4 Self-Compassion as Mediator Between Perf ectionism and Disordered Eating in Men ....704-5 Self-Compassion as Mediator Between Perfectionism and Disordered Eating in Women ......................................................................................................................... ......714-6 Internal Consistency, Means, and Standard Deviations of Study 2 Variables ...................72
8 LIST OF FIGURES Figure page 4-1 Change in Self-Compassion for Workshop Attendees ...................................................... 73
9 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy MALADAPTIVE PERFECTIONISM AND DISORD ERED EATING IN COLLEGE WOMEN: THE MEDIATING ROLE OF SELF-COMPASSION By Jennifer Stuart August 2009 Chair: Kenneth G. Rice Major: Counseling Psychology Disordered eating has been recognized as a concern on college campuses, particularly among college women. Maladaptive perfectionism has consistently been identified as a risk factor for disordered eating, and may present challenges to effective treatment and intervention. As a result, increased effort has gone into developing intervention st rategies that reduce maladaptive aspects of perfectionism such as fear of evaluation, discrepancy between standards and performance, and harsh self -criticism. Self-compassion, a construct drawn from Buddhist psychology, has recently emerged as a healthy self-attitude that is negatively related to maladaptive perfectionism. Although self-compassi on has been identified as a potential point of intervention in clinical settings, the relationshi p between self-compassion and disordered eating has not been examined. This research uses two studies to investigat e the role of self-com passion in explaining disordered eating in college wome n, as well as its potential integration into college counseling center outreach programming. Study 1 examin ed the relationships among maladaptive perfectionism, mindfulness, self-compassion, and disordered eating among 173 college students (105 women, 68 men). Study 2 employe d a single group pretest posttes t design to investigate the effects of a one hour outreach workshop on self-com passion in a sample of eight college women.
10 Consistent with predictions, self-compassion fully mediated the relationship between mindfulness and disordered eating and partially mediated the relationship between maladaptive perfectionism and disordered eating for college women. Furthermore, self-compassion scores increased significantly over the course of a one hour outreach workshop.
11 CHAPTER 1 INTRODUCTION Disordered eating h as been recognized as a serious concern in U.S. culture, and is particularly prevalent among young women. In fact, some studies have estimated that between 10% and 25% of women on a typical college campus experience some form of disordered eating (Kirk, Singh, & Getz; Meyer, 2005; Prouty, Pr otinsky, & Canady, 2002). Because of the complex constellation of processes that serv e to maintain disordered eating symptoms, disordered eating can be notorious ly challenging to treat (Baer, Fischer, & Huss, 2006; Kaplan & Garfinkel, 1999). As such, personnel on coll ege campuses have incr easingly turned to preventative programming in an effort to reduce th e incidence and severity of disordered eating among college students. Developing effective preventative programmi ng has proven challenging for researchers and practitioners. Universal prevention programs (those presented to the entire student population) have shown mixed results. The psychoeducational emphasi s of many of these programs, focused on recognizing signs of disord ered eating and/or en couraging help-seeking, may not translate into significant attitude or behavioral change. Although results have been inconsistent, there is also concern that programs that rely heavily on information-giving and testimonials may increase participants focu s on eating behavior, weight, and body image concerns, which may actually be harmful to those mo st at risk (Mann et al ., 1997). In an effort to address these limitations, recent prevention ef forts have focused on identifying individuals or subgroups who are more likely to develop disorder ed eating behavior, and have tailored activities toward reducing specific risk factors (Neumark-Sztainer, Levine, & Paxton, 2006; Wilksch, Durbridge, & Wade, 2008).
12 Perfectionism has been identified as a risk fa ctor for disordered eating (Bastiani, Rao, Weltzin, & Kaye, 1995; Lilenfeld, Wonderlic h, Riso, Crosby, & Mitchell, 2006), and preliminary research suggests that it is a promis ing target for prevention efforts (Wilksch, et al., 2008). Maladaptive aspects of perfectionism such as self-criticism, fear of evaluation, and perceptions of discrepancy, may be particul arly important to address (Ashby, Kottman, & Schoen, 1998). Individuals with elev ated levels of maladaptive pe rfectionism have an increased incidence of disordered eating, are less likely to seek help (M eyer, 2005), and have a more difficult time making progress in therapy (Bla tt, Quinlan, Pilkonis, & Shea, 1995; Goldner, Cockell, & Srikameswaran, 2002; Santonastaso, Friederici, & Favaro, 1999; Sutandar-Pinnock, Carter, Olmsted, & Kaplan, 2003). Higher levels of maladaptive perfectionism may make individuals more vulnerable to the influence of sociocultural risk factors (Brennan & Petrie, 2008). It seems to follow that addressing mala daptive aspects of perf ectionism may foster resilience and decrease risk of developing disordered eating. Buddhist psychology constructs may be particular ly well-suited to cultivating resilience. Buddhist psychology has become increasingly infl uential in Western psychotherapy in recent years (Germer, 2005, p. 10). Some researchers ha ve speculated that the inclusion of Buddhist psychology principles may lead to a more unified model of psychotherapy and aid in the integration of clinical theory, research, and practice (Germer, p. 11). Like Western psychotherapy, Buddhist psychology has as its pur pose the alleviation of human suffering and perceives a great deal of human suffering to be rooted in psyc hological causes (Fulton & Siegel, 2005, p. 29). However, Buddhist psychology depa rts from Western psychotherapy in some important ways. Rather than viewing suffering as arising from symptoms or from circumstances, Buddhist psychology sees suffering as a result of our relationship with the re alities of life (Fulton
13 & Siegel, p. 31). Because some amount of pain is inevitable in life, Buddhist psychology seeks to cultivate a different relations hip with painful realities, incl uding an attitude of curiosity, acceptance, and a present-moment awareness of how things actually are. This approach is designed to allow freedom within pain rather than creating freedom from pain. One of the most significant points of departure relates to the natu re of the self. Just as Western psychotherapy has as its goal the development of a healt hy, well-individuated se nse of self, Buddhist psychology seeks to foster insight into the insubs tantiality and impermanence of the self (Fulton & Siegel, pp. 39-40). Whereas Western psychotherapists might encourage the development of self-esteem, or positive self-evaluation, someone practicing Buddhist psychology might seek to cultivate self-compassion, or a nonjudgmental attitude toward se lf in the context of a shared human experience (Neff, 2003b). Principles drawn from Buddhist psychology su ch as mindfulness and, more recently, selfcompassion, have been increasingly integrated in to clinical practice (B aer, 2003; Neff, 2004). A number of promising interventions for disordered eating, such as Dialec tical Behavior Therapy (DBT; Linehan, 1993), Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999), and Mindfulness-Based Eating Awareness Training (MB-EAT; Kr isteller & Hallett, 1999), have Buddhist psychology prin ciples at their core. In contrast to many standard interventions for disordered eati ng that target eating behavior and food-related thought processes directly (Garner, Vitousek, & Pike, 1997; Touyz & Beaumont, 1997; Wilson, Fairburn, & Agras, 1997), these approaches emphasize nonjudgmental acceptance over goal-directed striving. Instead of targeting unwanted symptoms or their underlying cognitive distortions directly, Buddhist psychology has a more general goal of cu ltivating a clear percep tion of reality and an accepting, compassionate attitude toward self and experience. Such an approach may provide a
14 means of addressing maladaptive perfectionism and negative self-attit udes that underlie the development of disordered eating behavior and thus may be a promising component of prevention efforts as well. However, no study to date has examined the integration of Buddhist psychology principles into eating disorders prevention. The present study aims to examine the pot ential application of Buddhist psychology constructs to eating disorders prevention with college women. To accomplish this, several relationships will be explored. First, the study will examine the relationships between measures of maladaptive perfectionism, se lf-compassion, mindfulness, and disordered eating in college students. Maladaptive perfectionism and disord ered eating have a strong and well-established relationship, yet no study has examined their relationship from the perspective of Buddhist psychology. Previous studies ha ve established a moderately negative relationship between mindfulness and some measures of disordered eating (Baer, Fischer, & Huss, 2005; Kristeller & Hallett, 1999), and between self-compassion and maladaptive perfectionism (Neff, 2003a), but no study to date has examined all of these c onstructs in combinati on. Understanding the relationships among these constructs is an important first step in the deve lopment of theoretically sound prevention efforts. Next, a model will be examined in which mindfulness and self-compassion predict levels of disordered eating in college women. It is expected that self-compassion will account for (mediate) the relationship between mindfulness and disordered eating. Mindfulness and selfcompassion are related but conceptually distinct c onstructs that have shown different degrees of association with therapeutic ou tcomes such as alcohol use and other psychological symptoms (Rendon, 2006). Mindfulness can be defined as awareness of the present moment with acceptance and involves paying attention in a nonjudgmental way (Baer, 2003; Kabat-Zinn,
15 1994). Self-compassion is somewhat broader than mindfulness and involves a balanced awareness of ones own experien ce and a nonjudgmental kindness to ward oneself (Neff, 2003b). Participation in a mindfulness-based intervention ha s been related to improvements in disordered eating symptoms in numerous studies, and this relationship has been explained using several theoretical models of eating diso rder development. However, none of the existing studies have examined mechanisms that might explain this rela tionship. This study aims to begin closing this gap by examining self-compassion as a potential mediator. Rather than operationalizing mindfulness as participation in a mindfulness-based intervention, as was done in previous studies, the current study will measure mindfulness as a continuous variable using a self-report measure. As mindfulness-based interventions include not only mindfulness practice but also social support and therapeutic contact, it is unknown how much symptom change is actually attributable to mindfulness. Although this will not confirm causal pathways between mindfulness, self-compassion, and disordered eating symptoms, it is expected that this study will address some conceptual limitations of previ ous research and help identify more accessible targets of intervention and prevention efforts. Next, the study aims to examine a proposed model in which the relationship between maladaptive perfectionism and disordered eatin g is mediated by levels of self-compassion. Recent literature on the relationship between perfectionism and di sordered eating has suggested that maladaptive aspects of perfectionism (suc h as self-criticism and perceived discrepancy between standards and performance) may be part icularly problematic in the development of disordered eating while adaptive aspects of perf ectionism (such as setting high personal goals) do not necessarily lead to undesirable outcomes. As such, it is particularly important to identify ways of reducing maladaptive aspects of perfect ionism without interfer ing with its adaptive
16 components. Self-compassion may be promising in this regard because of its established negative relationship with maladaptive perfect ionism and non-relationship with adaptive perfectionism. However, no study to date has ex amined this relationship in the context of disordered eating. Finally, the study aims to examine the e ffects of a one-hour preventative outreach intervention designed to increase self-compassi on among college women. Previous efforts to increase self-compassion in a cl inical setting have typically involved multi-session small group interventions (Gilbert & Procte r, 2006; Shapiro, Astin, Bishop, & Cordova, 2005). Although the results of these interventions are promising, they are costly in terms of time and resources, and may require that individuals be in considerable distress befo re developing enough motivation to participate. As college counseling centers in creasingly focus on prevention activities, it is important to identify efficient means of engagi ng students who are most at risk before they develop significant problems. The present study aims to address this limitation by examining whether self-compassion can be increased using a brief, easily-employed outreach format. Thus, the overall aim of the current research is to explore the poten tial application of Buddhist psychology constructs (particularly self-compassion) to the prevention of disordered eating in college women, including the extent to which self-compassion can be cultivated in a single session outreach activity on a college campus. Chapter 2 will present a review of the relevant literature and outline specific research questions and hypotheses drawn from the existing literature. Chapter 3 will give an overview of study methodology, includ ing the participants, measures, intervention descriptions, and data co llection procedures. Ch apter 4 will present the results of this study, and Chapter 5 will discuss study implications and limitations. Key terms used in this study are listed and defined in Appendix O.
17 CHAPTER 2 LITERATURE REVIEW Eating Disorders Overview Eating disorders have received a gr eat deal of attention in rece nt literature. Controversies abound over proper identification and optim al trea tment, but most experts agree that these disorders stem from a complex etiology and pos e unique challenges in therapeutic intervention (Kaplan & Garfinkel, 1999; Stei n et al., 2001; Streigel-Moore & Cachelin, 2001). There are two primary categories of eating disord ers that are currently recognize d. Anorexia nervosa (AN) is characterized by a refusal to maintain a minimally normal body weight, an intense fear of gaining weight, and a disturbance in the experi ence of body weight or shape. Bulimia nervosa (BN) is characterized by recurrent episodes of binge eating followed by inappropriate or harmful compensatory behaviors (e.g., self-induced vom iting, laxative use, excessive exercise). Additionally, binge-eatin g disorder (BED), characterized by frequent binge eating without compensatory behaviors, and subthreshold presentati ons of all of these patterns are often treated under the category of eating disorders not otherw ise specified (EDNOS). Because of difficulty with identification and because of frequently changing diagnostic criteria, prevalence estimates for these disorders vary widely. In general, pr evalence estimates for eating disorders range from a lifetime prevalence of 0.5% for anorexia nerv osa to 5% for binge eating disorder. When subthreshold presentations are included, it is estimated th at 5-15% of women experience disordered eating at some point in their lifetime (Herzog, Kell er, Lavori, & Sacks, 1991). Unfortunately, these disorders are notoriously difficu lt to treat and can result in a host of harmful physiological consequences ( Baer et al., 2006; Kaplan & Garfinkel, 1999).
18 Eating Disorders on College Campuses Disordered eating m ay be especially pr evalent on college campuses. Although the proportion of college women meeti ng full diagnostic criteria fo r an eating disorder remains small, it is estimated that up to 61% of college women engage in some form of disordered eating behavior (Mintz & Betz, 1988). Proposed explanations for this phenomenon are abundant. Increased stress, discomfort with developmental bodily changes, increased freedom and control (including over diet) as a resu lt of newfound independence, and exposure to peer groups that promote thin ideals have been cited as contribu ting factors. Consistent with this assertion, Striegel-Moore, Silberstein, Frensch, and Rodi n (1989) surveyed 1040 undergraduate students at the beginning and end of their fi rst year in college, and found that students were more likely to increase than decrease disorder ed eating behavior over the course of the year. One fourth of students began dieting for the first time during th at year, and 15% of wo men began binge eating for the first time. In their study, increases in diso rdered eating behavior we re associated with an increased sense of ineffectivene ss, increased negative feelings a bout weight, and high levels of perceived stress. Numerous studies assert that prevalence is esp ecially high in certain subgroups of college women, including elite athletes, dancer s, and sorority members. It may be that the same challenges that increase risk for college stud ents in general (such as social pressure and desire for competence and self-definition) may be magnified by the instrumental role of weight, shape, and body image for these students (Alexander; 1998; Allison & Park, 2004; Garner, Garfinkel, Rockert, & Olms ted, 1987; Sigall, 1999). Eating Disorders Prevention Because college students are particul arly susceptible to the development of eating disorders, and because these disorders are often di fficult and costly to treat college campuses are increasingly turning to preventative programmi ng to reduce the incidence and severity of
19 disordered eating in their student s (Becker, Smith, & Ciao, 2005). However, empirical studies of such programs have identified numerous obstacles to effective prevention, the first of which may be identifying the appropriate target audience (M ann et al., 1997). Most campus programs focus on either the entire student popula tion, including those with no iden tified risk factors (primary prevention), or small subsets of students who endor se one or more specific risk factors for eating disorders, such as body dissatisfaction or re peated dieting (secondary intervention). Primary prevention programs, which are de signed to prevent st udents without eating disorder symptoms from ever developing symptoms, are typically psychoe ducational in nature. They often focus on giving information about signs and symptoms, risks associated with disordered eating behavior, and strategies for seeking help or referr ing someone for help. Numerous studies indicate that such interventions increase know ledge in the general population. However, evidence does not conclu sively indicate that these stra tegies result in behavioral change (Franko; 1998; Stice & Shaw, 2004). This ma y be because significant behavior change is unlikely in individuals who were at low risk to begin with (Fingeret, Warren, Cepeda-Benito, & Gleaves, 2006). There is some evidence indica ting that these programs are unhelpful (and may even be harmful) to students already exhibi ting eating disorder symptoms (Carter, 1997). Secondary prevention programs, on the other hand, seek to identif y people who are at increased risk for developing eating disorders, or who are perhaps already experiencing early stages of the disorders, and intervene early in the process. To accomplish this, these programs typically select individuals who exhibit specific risk factors, such as body image concerns or dieting behavior, and attempt to modify these ri sk factors. Secondary prevention programs may also normalize disordered eating as a response to sociocultural factors and attempt to reduce stigma associated with seeking help. Several secondary prevention programs have been utilized
20 effectively with high risk college populations (Becker et al., 2005; Hotelling, 1999; Sigall, 1999; Stice, Chase, Stormer, & Appel, 2000; Stice, Orjado, & Tristan, 2006). However, such programs may actually increase the incidence of disordered eating in low risk individuals because harmful behaviors are normalized (Mann et al., 1997). Furthermore, it is difficult to reliably identify individuals who exhibit eatingdisorder-specific risk factor s at an early enough stage to implement prevention activities. This is made even more difficult by the relative lack of consensus on the etiology of disordered eating (Streigel-Moore & Cachelin, 2001). Although many researchers conceptualize prevention as falling into one of two categories (primary vs. secondary prevention), an alternativ e lens differentiates betw een disease-specific vs. non-specific prevention. Unlike eating disorder s prevention programs that focus almost exclusively on the strongest proximal correlat es of disordered eating (most of which are explicitly related to food and body issues), nonspecific prevention focuses on decreasing general vulnerability and increasing resilience. For inst ance, the non-specific vul nerability stress model (NSVS; Levine & Smolak, 2001) pos its that there are generic sour ces of stress and vulnerability that are part of the pathways to multiple disorders. This is supported by the co-occurrence of many mental health concerns (such as eating diso rders and anxiety or mo od disorders) and the link between environmental stressors and a rang e of undesirable behavioral outcomes (Durlak, 1997; Kaplan & Garfinkel, 1999). Consistent with this model, some researchers have suggested that prevention efforts should first identify s ubgroups of the population that may have more psychological vulnerability because of personal or social characteristics, and then address the source of vulnerability (Franko & Orosan-Weine, 1998). In addition to de creasing the risk of eating disorders in particular, th is approach is expected to enhance wellness in the larger community (Levine & Smolak, 2006).
21 In order to address sources of underlyi ng psychological vulnerability, it becomes important for prevention efforts to extend beyond information giving. Irving (1999) encourages a decreased emphasis on the pathology of eating di sorders, and an increased focus on enhancing human resiliency. For instance, prevention programming could include skill development, personal empowerment, and self-esteem enhancem ent. Although these elements are sometimes built into primary prevention programs, particularly at the elementary or middle school level, a minority of university counseling centers integrate skill developm ent or a resiliency focus into eating disorders prevention outreach (dos Santos, 2004). Because of this, there are few available models and little is known about the effectiveness of such an approach. Eating Disorders and Perfectionism Although eating disorders can be variously categorized based on symptomatic features, it is thought that they share cruc ial underlying psychologi cal characteristics th at transcend foodand weight-related behavior. According to nons pecific models of eating disorders prevention, these processes provide an appr opriate focus for prevention efforts (Levine & Smolak, 2006). Fairburn, Cooper, & Shafran (2003) proposed a tran sdiagnostic theory of eating disorders in which seemingly disparate clinical features are initiated and ma intained by similar psychological processes. One of these processes is thought to be perfectionism, or the setting of high (sometimes impossibly high) standards accompanie d by self-evaluation based on the meeting of these standards. Perfectionism is so commonl y associated with eating disorders that these disorders have been summarily described as the relentless pursuit of an ideal (body, shape, diet) followed by intense feelings of shame when this ideal is not reached. Researchers have noted that, across diagnostic categories, the core features of eating diso rders appear to be inherently perfectionistic in nature (Gol dner et al., 2002). A gr owing number of empirical studies support this relationship and indicate that the link betw een perfectionism and eating disorders is strong
22 and complex (Bardone-Cone et al., 2007; Franco -Paredes, Mancilla-Diaz, Vazquez-Arevalo, Lopez-Aguilar, & Alvarez-Rayon, 2005). Perfectionism has been implicated as a substantial risk factor in the development of disordered eating. In addition to being notably elevated in individuals with eating disorders diagnoses compared with non-diag nosed individuals (Bastiani et al., 1995; Lilenfeld et al., 2006), there is evidence that perfectionism tempor ally precedes the onset of disordered eating symptoms (Fairburn, Cooper, Doll, & Welch, 1999). Additionally, levels of perfectionism tend to remain elevated even after di sordered eating improves, suggesting that perfectionism is a more stable underlying trait and not the result of di sordered eating behavior (Bardone-Cone et al., 2007; Bastiani et al., 1995). Levels of perfec tionism differ minimally across eating disorders diagnoses. At the same time, there is evidence that perfectionism is higher in individuals with eating disorder diagnoses than in individuals with either mood or anxiety disorders (BardoneCone et al.). Although many studies linking perfectionism with disordered eating emphasize the harmful nature of perfectionism, some res earchers conceptualize perfectionism as a multidimensional construct with both adaptive a nd maladaptive elements (Davis, 1997; Suddarth & Slaney, 2001; Terry-Short, Owens, Slade, & Dewey, 1995). Adaptive components of perfectionism include the setting of high personal standards, the pursuit of positive reinforcement, and striving to reach high goals Maladaptive components include fear of evaluation by others, harsh self-criticism, and the perception of discrepancy between goals and performance (Rice & Ashby, 2007; Terry-Short et al., 1995). Adaptive components of perfectionism have been associated with largel y desirable characteristics and outcomes such as self-esteem, self-efficacy, secure relationship att achments, and academic integration (Grzegorek,
23 Slaney, Franze, & Rice, 2004; Rice & Mirzadeh, 2000) At the same time, maladaptive aspects of perfectionism has been associated with more problematic outcomes, including depressive symptoms, bulimic symptoms, and general ps ychological distress (Aldea & Rice, 2006; Bardone-Cone, Weishuhn, & Boyd, 2009; Rice & Ashby, 2007). When approached from this perspective, the relationship between perfectionism and disordered eating symptoms becomes more comp lex. Although several st udies have suggested that individuals with eating diso rders have elevated levels of both adaptive and maladaptive perfectionism, others have suggested a unique role for maladaptive perfectionism. For instance, Ashby, et al. (1998) reported that participants diagnos ed with eating disorders showed higher levels of maladaptive perfectio nism than participants withou t eating disorders, but scored comparably on a scale measuri ng adaptive perfectionism. Pearson and Gleaves (2006) reported that adaptive aspects of perfectionism corre lated positively with body satisfaction and had virtually no relationship with bulimic behavior, while a maladaptive dimension of perfectionism was related to lower self-esteem, higher body diss atisfaction, and increased bulimic behavior. Similarly, Bardone-Cone and coll eagues (2009) found that malada ptive perfectionism, but not adaptive perfectionism, moderated the relationship between perceived weight status and bulimic symptoms in a group of African-American coll ege women. Still othe r researchers have suggested that adaptive and malada ptive dimensions of perfectionism are interconnected factors. Davis (1997) reported an interact ion between adaptive and malada ptive perfectionism in which adaptive perfectionism was related to higher body esteem but only when maladaptive perfectionism was low. When maladaptive pe rfectionism was high, the relationship actually reversed. Taken together, these results could indicate that ad aptive aspects of perfectionism (such as high personal standards and perfectionist ic strivings) are not in themselves problematic,
24 but create an increased risk when they are accompanied by maladaptive aspects of perfectionism such as self-criticism and concerns over evalua tion. These maladaptive aspects of perfectionism in turn may leave individuals more vulnerable to other sources of eating disorders risk, such as perceived weight status and body dissatisfaction (Bardone-Cone et al., 2009; Brannen & Petrie, 2008). Perfectionism and Eating Disorders Intervention In addition to serving as a setting conditi on for the development of disordered eating, perfectionism has been indicated as a complicat ing factor in eating disorders treatment. A growing body of literature has linked perfectio nism with negative therapeutic outcomes (premature termination, higher rates of relapse) across psychological disorders and treatment modalities (Blatt et al., 1995). It is therefore not surprising that perfectionism has been implicated a contributing factor to the challenge of treating individuals with eating disorders (Kaplan & Garfinkel, 1999). Seve ral studies have examined perfectionism as it relates to eating disorders treatment in particular, and have s uggested that higher pre-treatment levels of perfectionism are predictive of more problema tic treatment outcomes. This seems to be particularly true in individuals diagnosed with anorexia nervosa, but has also been shown in a mixed clinical sample of indi viduals with eating disorders (Santonastaso et al., 1999; SutandarPinnock et al., 2003). Goldner et al. (2002) have described several possible explanations for this relationship. Because of high levels of self-critic ism and an inner sense of not being good enough, individuals with high levels of perfectionism may be part icularly averse to discussing problems as these might be construed as personal failures. As a result, it may be difficult for these individuals to form a trus ting therapeutic relationship. At the same time, these individuals may be extremely self-critical of their own pr ogress in therapy, quickly becoming dissatisfied with the imperfect nature of th e process. Hence, high levels of perfectionism may both impede
25 the therapeutic process and lead to prem ature termination. The challenges posed by perfectionism may be particularly pronounced in the treatment of disordered eating because the symptoms at the focus of treatment are so inti mately connected with the quest for perfection. Any attempt by the therapist to support weight gain or reduce striving may be interpreted as being supportive of failu re (Goldner et al.). Because of the well-estab lished role of perfectionism in the development and maintenance of disordered eating, perfectionism sta nds out as an important target of intervention. Unfortunately, there has been litt le exploration of approaches specifically designed to address maladaptive aspects of perfectionism in individua ls with eating disorders (Goldner et al., 2002). While some existing interventions target cognitive processes such as high standards and the need for order (Garner et al., 1997; Stei n et al., 1991), perfec tionistic individuals may be reluctant to give up strategies from which they derive benefits. Furthermore, these aspects of perfectionism may be adaptive and less significant in the de velopment of disordered eating (Ashby et al., 1998). Therefore, it may be more effective to focus on the reduction of maladaptive aspects of perfectionism such as self-critic ism and anxiety about performance. As a result, further study is needed on approaches designed not to challenge individuals high standards but to increase acceptance of self and experience. Perfectionism, Eating Di sorders, and the Self According to some conceptualizations, the link between perfectionism and eating disorders exists so strongly because both represen t attempts to cover up inner self deficits or compensate for a deep sense of ineffectiven ess (Bruch, 1973, 1978; Goodsitt, 1997). From the perspective of self psychology (Kohut, 1971), both maladaptive perfectionism and disordered eating can be understood as the result of disrupti ons in self-development (B achar, Latzer, Kritler, & Berry, 1999; Rice & Dellwo, 2002). According to self psychology, disorders of the self result
26 when early caregivers are chronically unresponsiv e to a childs early de velopmental needs for mirroring and idealization. Small la pses in parental empathy are e xpected and can facilitate the development of a well-defined, indi viduated self. However, a tr aumatic or pervasive lack of parental empathy results in a sense of self that is unclear, unstable, a nd highly susceptible to change based on external events. According to Sorotzkin (1985), perfectionistic strivings sometimes arise as an attempt to maintain a st able sense of self. Similarly, Goodsitt (1997) described symptoms of disordered eating as an individuals emergency measures to restore a sense of vitalization, wholeness, or effectiveness. The meticulous control inherent in disordered eating functions by providing the individual wi th a temporary feeling of strength and effectiveness to cover up the underlying feelings of weakness, shame, and inadequacy (Goodsitt, p. 210). In addition to providing escape from the emotional experience of painful self-states, the disordered eating may provide a compensatory se nse of selfhood or identity that enables a person to feel that they have a significant role in the world. In contrast to psychoanalytic conceptualizations, which emphasize the relative intactness of the self, a number of recent conceptualizations (e.g. CBT) treat both perfectionism and disordered eating as attempts to escape something aversive (Heathert on & Baumeister, 1991). These conceptualizations emphasize the role of un healthy self-attitudes su ch as self-criticism, low self-esteem, and negative self awareness (Fairburn, 1997; Wilson et al., 1997). For instance, Beebe (1994) built on a model of binge eating as escape from aver sive awareness (Heatherton & Baumeister, 1991) and extended it to include diet ing and restrictive eatin g behavior. According to Beebes model, the failure to meet excessively high perfectionist ic standards leads to negative self-awareness. This awareness leads to dieting behavior which is likely to fail. The act of dieting leads to increased vigilance and awaren ess of shortcomings, wh ile also leading to
27 negative affect when dieting attempts are not successful. Individuals may increase dieting behavior in a continued attempt to meet failed goals. Alternatively, they may become more susceptible to binge eating in order to escape the negative affect. In this model, perfectionism creates the initial dissatisfaction necessary for the rest of the cycle to unf old, while also helping to perpetuate it as individuals continually a ttempt to meet their unrealistic goals. More recently, Fairburn et al (2003) have integrated thes e concepts with a cognitive behavioral approach to propose a transdiagnostic treatment for eating disorders. Building on a traditional cognitive behavioral approach to ea ting disorders that emphasizes the individuals cognitions related to shape, weight, and food a nd the relative importance placed on these in a persons life, Fairburn et al. proposed a number of broader cognitive patterns that may interact with food-specific beliefs to perpetuate eating di sorder symptoms. Among these were core low self-esteem, or the tendency to negatively evaluate oneself regardless of performance, and perfectionism. According to this view, some i ndividuals hold themselves to excessively high standards and consistently judge themselves hars hly. Thus, they are more likely to perceive failure in their efforts. This perception, comb ined with other mainte nance factors (such as difficult interpersonal relationships ) leads to uncomfortable mood st ates and a need to escape or dull these states through disordered eating. Although these explanations differ significan tly from each other and from earlier psychoanalytic models, they share important commonalities. These commonalities may be important to consider in the development of e ffective treatments. In all of these models, perfectionism has an important role in the deve lopment of eating disorders. Just as self psychologists view disordered eating as a specific manifestation of a more general perfectionistic attempt to maintain a cohesive self, cognitive-behavioral models have indicated a more active
28 role for perfectionism in which it leads to negative self-attitudes, and in turn arises in order to ameliorate these self-attitudes. Common in thes e models is the idea th at striving for outward perfection is related to an underl ying sense of something being wrong or flawed either deep within the person or in the cont ext of life goals. Something a bout the persons experience feels unacceptable and must be covered up, fixed, or escaped. These models indicate that perfectionism and disordered eating are closely re lated processes, each designed to fulfill this function. Perspectives from Buddhist Psychology Increasingly, concepts drawn from Buddhi st psychology have been integrated into Western psychotherapy to inform the understand ing of psychological suffering and to improve psychotherapeutic practice (Epstein, 1995; Fulton & Siegel, 2005, p. 28). Like Western traditions, Buddhist psychology seeks to alleviate human suffering and sees much suffering as arising from psychological causes (Fulton & Siegel, p. 29). However, it is important to note that these perspectives stem from entirely differe nt worldviews and therefore differ on some fundamental understandings (Kabat-Zinn, 2003). One important point of departure be tween Buddhist psychology and Western psychotherapy involves the understanding of th e self. Western thought emphasizes the importance of a healthy, well-indivi duated self and views an individu al as a distinct unit. As a result, psychotherapy typically focuses on restorin g individuals sense of autonomy, by means of self-esteem, self-efficacy, and clear boundaries between self and others. Buddhist psychology, by contrast, is based around the concept of no-self and seeks to illuminate the insubstantiality of the self (Fulton & Siegel, 2005, p. 40). Rath er than regarding low self-esteem or selfjudgment as a symptom that should be the focus of treatment, Buddhist psychology sees the problem as lying in the initial belief of the self as a separate entity. Within this framework,
29 individuals move closer to enli ghtenment as they begin to re alize the transient nature of experience and develop insight into self as a proc ess (Fulton & Siegel, p. 41). In light of this, Buddhist psychology typically seeks to diffuse boundaries between individuals (which are viewed as arbitrary) rather th an enhance them, and increase a persons sense of compassion and interconnectedness. Self-Compassion This view of the self (or noself) is reflected in the rece ntly introduced c oncept of selfcompassion (Neff, 2003b). An important con cept in Buddhist thought (Bennett-Goleman, 2001; Hanh, 1997), self-compassion can be defined as the ability to be open to ones own suffering, not avoiding or disconnecting from it, while generating the desire to alleviate ones suffering and to heal oneself with kindness (Neff, 2003). It ha s been described as an open-hearted way of relating to negative aspects of oneself and ones experience (Neff & Lamb, 2009). It is conceptualized to have three interconnected components: se lf-kindness rather than harsh judgment and self-criticism, emphasis on common humanity rather than on separation and isolation, and mindfulness toward ones painful thoughts and f eelings rather than overidentification with them. Just as compassion fo r others involves an at titude of nonjudgmental understanding toward others suffering, self -compassion involves offering nonjudgmental understanding to ones own experiences, incl uding personal inadequacies and failures. Consistent with the Buddhist not ion of no-self, self-compassion involves de-emphasizing ego boundaries and seeing ones expe rience as part of the larger human experience. Self-compassion has been put forth as an alternative conceptualization of a healthy attitude toward self (Neff, 2003b) and as suc h, may serve as a useful intervention point for individuals with unhealthy self-att itudes (self-criticism, self-judg ment, etc.) Self-compassion is theorized to be more stable than feelings of self-esteem and less contingent on particular
30 outcomes. Furthermore, it has emerged as a si gnificant predictor of happiness, optimism, and positive affect, explaining additional variance af ter global self-esteem wa s accounted for (Neff & Vonk, 2009). Unlike self-esteem, which has been a ssociated with some undesirable outcomes such as self-absorption, aggres sion, and distortions in self-kno wledge (Baumeister, Smart, & Boden, 1996; Crocker, Thompson, McGraw, & Inge rman, 1987), self-compassion encourages a kind and understanding attitude toward self while countering attitudes of egocentrism and emphasizing interconnectedness. Because of its emphasis on interconnectedness and shared experience, self-compassion is thoug ht to soften, rather than enha nce, ego-defensive boundaries. As would be expected, it has been shown to have a negative association with social comparison, public self-consciousness, and self-rumination (Neff & Vonk). Though empirical research on self-compassion is relativ ely new, already some relationships have emerged with various as pects of psychological functioning. Scale development studies indicated that self-com passion correlated negatively with depression, anxiety, and maladaptive perfectionism and positivel y with life satisfaction (Neff, 2003a). In other studies, increases in self -compassion have been linked to increases in psychological wellbeing (Neff, Kirkpatrick, & Rude, 2007) and lowe r levels of perceived stress (Shapiro et al., 2005). Approaching difficulties in a self-compassi onate manner has been linked to higher levels of happiness, optimism, personal initiative, and re flective wisdom. These relationships remained after five major dimensions of personality were accounted for (Neff, Rude & Kirkpatrick, 2007). Self-compassion may be particularly benefi cial in the case of unpleasant self-relevant events. For instance, Neff, Hs ieh, & Dejitterat (2005) found that students levels of selfcompassion was related more strongly to mast ery goals rather than performance goals, and translated into greater resili ence in the face of academic setb acks. Students high in self-
31 compassion perceived themselves as competent a nd exhibited less fear of failure than students low in self-compassion. Leary, Tate, Adams, A llen, and Hancock (2007) conducted five studies examining reactions to unpleasant life ev ents, and found that self-compassion buffered participants against emotional di stress and negative self-feelings in the case of potentially distressing events. Interestingly, self-compassion was associated with lower levels of negative affect in the event of negativ e feedback, while self-esteem had no such buffering effect. In addition, self-compassion seemed especially impor tant when self-esteem was low. Although low self-esteem was generally related to emotional di stress following negative feedback, high levels of self-compassion attenuated this relations hip. Furthermore, unlike self-esteem, selfcompassion was related to an ability to percei ve ones performance accurately. In light of findings such as these, self-compassion has been proposed as an effective means to counter negative self-attitudes (Neff, 2003b). Mindfulness and Psychotherapy Mindfulness, a concept at the heart of B uddhist psychology, involves bringing ones full attention to the present moment. It can be defined as paying a ttention in a particular way: on purpose, in the present moment and nonjudgmentally (Kabat-Zinn, 1994, p. 4) and is said to involve an affectionate, friendly sense of presence and intere st (Kabat-Zinn, 2003). Mindfulness meditation, one of the core practices of the Buddhist tradition, has been described both as a set of techniques or skills and as a way of being (Kabat-Zinn, 2005, p. 64). It has been called the method of no method. In essence, it is becomi ng aware of the present reality and resting in what is already there (Kabat-Zi nn, p. 65). It is a state that occurs naturally (although, possibly infrequently) in everyday life and requires practice to maintain (Germer, 2005, p. 13). Recently, mindfulness has been la rgely separated from its religious context and infused into a growing number of therapeutic practices (Baer, 2003; Roemer & Orsilllo, 2003). One of
32 the earliest systematic uses of therapeutic mindfulness was conducted by Kabat-Zinn (1982) and was designed for chronic pain patients. Th is approach, dubbed mindfulness-based stress reduction (MBSR) has become a widely used th erapeutic intervention and has been modified and applied to a number of client populations and problems. Mindfulness is also a core component of several more recently developed therapies including mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasda le, 2002), acceptance and commitment therapy (ACT; Hayes et al., 1999), dialectical behavior therapy (DBT; Lineha n, 1993), and mindfulnessbased eating awareness training (M B-EAT; Kristeller & Hallett, 1999 ). These approaches differ in the way mindfulness is integrated into trea tment. However, mindfulness-based therapeutic approaches share some common features. Typica lly, they encourage an individual to become aware of and attentive to internal experiences such as thoughts and emotions, and to observe these using a de-centered, nonj udgmental stance (Baer, 2003). In many approaches, some aspects of formal mindfulness training (sitti ng meditation, hatha yoga, body scan, mindful eating, etc.) are used to facilitate this awareness. These practices involv e a shared set of key attitudes, including nonjudgment, non-striving and beginners mind, or the ability to encounter present experience as if seeing it for the first time (Kabat-Zinn, 1990). Through practice, individuals become more familiar with the transient nature of thoughts and experience and are more able to encounter their moment-to-moment experience w ithout getting caught up in it. This way of thinking allows more flexibility in perception an d allows the mind to open to new possibilities. This set of attitudes is thought to free particip ants from the pressure of making progress and help them experience themselves as already okay (Kabat-Zinn, p. 37). The earliest empirical studies of mindfulne ss-based therapy involved pain management with medical populations. These early studies demonstrated that mindfulness practice might
33 help reduce the physical and mental impact of c onditions such as chronic pain, fibromyalgia, and cancer (Kabat-Zinn, Lipworth, & Burney, 1985; Kaplan, Goldenberg, & Galvin, 1993; Speca, Carlson, Goodey, & Angel, 2000). Most early studi es had substantial methodological limitations such as single group designs, they establishe d that patients who took part in mindfulness interventions experienced a decrease in pa in, improved medical symptoms, and general psychological improvements (Baer, 2003). More recent studies have begun to incorporate greater experimental control, a nd have continued to show promising results. For instance, Kabat-Zinn et al. (1998) randomized 37 psoriasis patients receivi ng light therapy to either a treatment-as-usual group or a treatment-as-usual plus mindfulness group. The patients who received mindfulness training as part of their treatment experienced a significantly faster improvement in psoriasis symptoms compared to the patients who received only light therapy. In order to further examine th e physiological effects of mindf ulness, Davidson et al. (2003) assigned 41 participants to eith er an eight week mindfulness-based stress reduction (MBSR) group or a wait-list control group and measured brain activation and immune functioning before and after the intervention, as well as four months later. The mindfulness participants showed a changed pattern of brain activation consistent in pa rts of the brain associated with positive affect as well as increased immune functioning. In recent years, mindfulness has been rela ted to a broad range of psychotherapeutic outcomes. Kutz et al. (1985) investigated the use of an adjunctive 10-w eek MBSR program with a group of 20 psychotherapy patients. Although it is difficult to draw specific conclusions from this study because of the single group design, participants reported an improvement in psychological symptoms and less interference in their daily functioning. Mindfulness-based approaches have also fared well when tailored to a specific cl inical problem. For instance,
34 Kabat-Zinn et al. (1992) surveyed 22 individuals diagnosed with generalized anxiety and panic disorders, and found significant improvements in a nxiety and depression afte r participation in an eight week MBSR program. It is impossible to estimate whether this approach was more effective than standard treatment, but a thre e-year follow-up study of the same individuals indicates that gains were meaningful and long-lasti ng (Miller, Fletcher, & Kabat-Zinn, 1995). Teasdale et al. (2000) examined the effects of an eight week mindfulness-based cognitive therapy (MBCT) program for individuals diagnosed with major depressive disorder. They found that the mindfulness-based appro ach was more effective in preventing relapse (compared to treatment-as-usual) for individuals with a history of three or more major depressive episodes. In addition to improving a broad range of targeted symptoms, mindfulness-based interventions have been linked to improved physical, emotional, spiritual, and interpersonal functioning in non-clinical populatio ns (Astin, 1997; Shapiro et al., 2005; Shapiro, Schwartz, & Bonner, 1998). Volunteers from student and co mmunity populations have reported changes such as decreased perceived stress, decreased job burnout (Shapiro et al., 2005), increased empathy and improved interpersonal relationships (C arson, Carson, Gil, & Baucom, 2004), greater satisfaction with life, an d greater spiritual well-b eing (Astin, 1997). Self-perceived changes have included increased openness to change, increased self-control, personal gr owth, spirituality, and the sense of a shared experience (Macke nzie, Carlson, Munoz, & Speca, 2007). Not surprisingly, mindfulness practice has increasingly bee associated with improved well-being and quality of life (Brown & Ryan, 2003). Given the wide array of physiological and psychological outcomes associated with mindfulness practice, researchers have put forth a number of theo ries regarding the mechanisms of change in mindfulness-base d interventions. One frequently cited mechanism involves
35 exposure to unpleasant physical or emotional experiences (Kabat-Zi nn, 1982; Linehan, 1993). Similar to desensitization, the oppor tunity to observe th e transient nature of painful experiences may help alleviate excessive emotional reactivity typically elicited by primary symptoms. This is similar to the notion of acceptance commonl y discussed in the psychotherapy literature (Hayes, 1994) and becomes especi ally relevant in instances in which physical or emotional sensations are thought to trigger other aspects of suffering such as panic disorder (Kabat-Zinn et al., 1992), binge eating disorder (Telch, Agras, & Linehan, 2000), and borderline personality disorder (Linehan, 1993). Another potential mechanism involves changes in cognition. Cognitive changes induced through mindfulness differ from those achieved through CBT in that the content of thoughts does not necessarily ch ange (Baer, 2003). In stead, the individuals attitudes about the thoughts change s and they are regarded as jus t thoughts instead of absolute reality. This is particularly applicable in cas es in which ruminative or self-defeating cognitions are thought to play a causal role such as binge eating disorder (Kristeller & Ha llett, 1999) and major depressive disorder (Teasdale, Segal, & Williams, 1995). More generally, it is thought that mindfulness-based approaches may lead to change through improvements in selfmanagement that occur when individuals are mo re aware of their sensations and experiences (Baer, 2003; Kabat-Zinn, 1982). Early recognition of cognitive and emotional patterns may enable individuals to respond, ra ther than react, to stressors (Dobkin, 2008). This heightened awareness allows time to more consciously c hoose a coping strategy and may be particularly relevant for individuals who enga ge in impulsive behaviors (Lin ehan; Teasdale et al.). Mindfulness and Self-Compassion While m any proposed mechanisms of acti on in mindfulness practice can be closely analogized to cognitive or behavi oral constructs, some practitione rs have noted that mindfulness also has the potential to change a persons sense of self and th eir sense of themselves in the
36 world. For instance, one of the most unique heal ing aspects of mindfulness has been said to be the sense of wholeness that comes from seei ng through the distortions created by old patterns of thinking (Kabat-Zinn, 1990, p. 160). In additio n to a sense of wholeness and connectedness within oneself, mindfulness can cr eate a sense of interconnectedne ss and a realization of being part of a larger whole (Kabat-Zinn, p. 164). In light of this, it is not surprising that some researchers have nominated self-compassion as a mechanism through which mindfulness effects therapeutic change (Shapiro et al., 2005). As is evident from the conceptualization of selfcompassion articulated by Neff (2003b; 2004), self-compassion is clos ely related to yet distinct from the construct of mindfulness. Self-com passion cannot be reduced to mindfulness, but requires mindfulness in order to develop. Self-compassion requires an attitude of kindness toward ones experience, and it is the mindful awareness of mo ment-to-moment experience that creates enough mental space for this observation to occur (Neff, 2004). Shapiro, Brown, and Biegal (2007) measur ed mindfulness, self-compassion, and a number of mental health outcomes in a group of counseling psychology students participating in an eight week mindfulness-based stress reduc tion program. As expected, the students participating in the program experienced grea ter gains in mindfulness and self-compassion and greater reduction in psychologica l symptoms than students participating in an alternative intervention. Even more intere stingly, changes in mindfulness from the beginning to the end of the study significantly predicted gains in se lf-compassion. This emphasizes the highly interrelated nature of these constructs, and sugge sts that self-compassion can be cultivated using a mindfulness-based intervention (Neff & Vonk, 2009) Although researchers have only recently begun systematically studying this construct, ther e is evidence that self -compassion may at least partially account for changes in psychological sy mptoms and improvements in well-being that
37 occur during mindfulness-based interventions (Ne ff & Lamb, 2009). For instance, in a study of health care professionals, increases in self-c ompassion significantly predicted changes in perceived stress after participation in a mindf ulness intervention (Shapiro et al., 2005). Mindfulness and Disordered Eating In an attem pt to target some of the unde rlying processes that initiate and maintain disordered eating behavior, mindfulness-based appr oaches have increasingly been incorporated into eating disorders treatment (Kristeller, Baer, & Quillian-Wolever, 2006). This makes theoretical sense given the close match between many of the core philosophies of mindfulness and some of the processes thought to be at the root of disordered ea ting. For instance, an increased ability to observe ones thoughts and experiences without reacting may decrease the tendency to escape from aversive self-awareness. Furthermore, a nonjudgmental stance toward experience may directly address the self-critical aspects of perfectionism that are so closely linked with disordered eating. Much of the work linking mindfulness and di sordered eating has related to binge eating disorder (BED). Kristeller a nd Hallett (1999) examined the use of a six week MBSR group (dubbed mindfulness based eating awareness training, or MB-EAT) for 18 women with BED. The intervention used both gene ral meditation instructions and instructions specific to eating behavior. Post-test and follow up assessment indi cated that the women experienced a decreased frequency and severity of binging and improved sc ores on other mental health measures. Telch et al. (2000) also noted the a pplicability of mindful ness skills in their adaptation of DBT for women with BED. Within the 20-week manuali zed treatment, participants were taught to observe the ebb and flow of their moment-to-mo ment experiencing and become familiar with the transient nature of their emotional reactions. In an uncontrolled trial with eleven women, the authors found that most (82%) had ceased bing ing by the end of the treatment, and this
38 improvement remained at follow-up. Participan ts also demonstrated an improvement in emotional regulation. More recently, Baer et al. (2005) adapted mindfulness-based cognitive therapy for women with BED. This approach involved teaching a body s can, mindful stretching and walking, mindful eating, and sitting medita tion in addition to cognitive exercises to encourage an accepting and nonreactive attitude to ward cognitions. In a pilot study with ten women, the authors found that a ten session inte rvention led to improveme nts in terms of the number of binges and eating-related concerns. The authors also noted the increase of mindfulness skills and an increased sensitivity to bodily sensations, including the ability to discern hunger from other sensations. Recently, researchers have examined the re levance of mindfulness-based approaches for women with anorexia nervosa (AN) and bulimia nervosa (BN). Safer, Telch, and Agras (2001) built on earlier work relating DBT and BED, and examined the use of a 20-week DBT intervention with women with bulimia nervosa. Using a randomized pre-post-follow up design, the authors found that participants in the DBT group experienced signific antly fewer binges than participants in the wait list control group. In contrast to the high dropout rate noted in some treatments for bulimia (Agras, Fairburn, Walsh, Wilson, & Kraemer, 2000) none of the participants in the DBT group dr opped out of treatment. Although very few empirical studies have examined application of mindfulness-based interventions to anorex ia nervosa, Heffner, Sperry, Eifert, & Detweiler ( 2002) reported a case study in whic h they employed acceptance and commitment therapy (ACT) with an anorexic 15-y ear-old girl. In this adaptation of ACT, a mindful approach is applied to body-related thoughts. Rather than fighting against unwanted cognitions, clients practice accepting them and le tting them pass. The authors described the
39 treatment as successful but also noted that the mindfulness elements were combined with other standard techniques. Although mindfulness-based approaches have shown considerable promise in the reduction of eating disorder symptoms, there is re latively little agreement as to the processes underlying these changes. Researchers have connected mindfulness with disordered eating based on one of several existing ea ting disorders theories. For in stance, within the experiential avoidance model of disordered eating (Heat herton & Baumeister, 1991), mindfulness may reduce symptoms through exposure to and acceptan ce of unpleasant emotional stimuli (Linehan, 1993). This exposure reduces the need to use food-related behaviors to avoid distress. Cognitive behavioral models relate mindfulness to disordered ea ting at the level of cognition. According to the cognitive behavioral model of bulimia nervosa, fo r instance, distorted cognitions both about the importance of weight a nd shape and the interpreta tion of failure play a crucial role in the maintenance of disordered ea ting (Wilston et al., 1997). Within this model, mindfulness may be helpful because it enables a person to disengage from their thoughts and recognize them as just thoughts. Instead of ch allenging the distortions directly, mindfulness acts by changing a persons relati onship with these cognitions. This creates a space for a person to choose how to act, rather than being driven entirely by their beliefs and cognitions. Goldner et al. (2002, p. 332) ha ve created an integrated model of perfectionism and disordered eating that may be helpful in unders tanding the role of mindf ulness in the treatment of disordered eating. According to this integrat ed model, perfectionism creates aversive selfawareness, or the awareness that the individual is not meeting self-imposed standards. At this point, an individual may make attempts at se lf-improvement through re strictive dieting, or attempt to escape from this aversive self-a wareness through binging. Because of the self-
40 criticism inherent in perfectionism, either acti on leads to intensified feelings of failure and reduced self-worth, which in turn intensifies the need to either eliminate the discrepancy (through dieting) or escape awareness (through bi nging). In this way, the development of disordered eating involves a f eedback loop where unrealistically high standards lead to inevitable failure. The resultant self-criticism eventually leads to even more compulsive attempts to set and meet impossibly high standa rds. It is important to note that these mechanisms operate within a framework informed by sociocultural influences and temperamental factors. For instance, the infl uence of perfectionism on eating behavior is strengthened when, through soci ocultural influences, shape or weight becomes a substantial contributor to self-esteem. A lthough mindfulness has not been examined in the context of this model, this framework points to several mechanisms through which mindfulness could be helpful. Perhaps most obviously, mindful ness may interrupt the cycle by fostering compassionate self-attitudes in place of self-criticism. If that is the case, perfectionism may still lead to a noticeable discrepancy between perfor mance and standards, but an individual may be less likely to perceive it as a personal failure a nd will be less likely to use harsh self-criticism. Because the discrepancy does not severely impact feelings of self-wor th, there would be less need to improve or escape. Similarly, mindf ulness may operate by increasing an individuals ability to tolerate unpleasant emo tional experiences. In this case, even if an individual observes a discrepancy and feels uncomfortable with it, the n eed to eliminate the feeling is less urgent. In short, the self-compassionate attitudes fostered by mindfulness training may interrupt the process fueled by self-criticism and may weaken the relationsh ip between perfectionism and disordered eating behavior.
41 There are several limitations in the exis ting literature linking Buddhist psychology constructs (both mindfulness and self-compassion) with perfectionism and disordered eating. These constructs have been most frequently studied in the context of mindfulness-based interventions, and existing studies have investigated a range of interventions which vary widely in the degree to which they incorporate mindfulness into treatment. In many cases, mindfulness is operationalized as participation in the treatment. Whereas some interventions, such as MBSR (Kabat-Zinn, 1982) use mindful ness meditation as a core component of treatment, others such as ACT (Hayes et al., 1999) and DBT (Linehan, 1993) incorporate mindfulness principles but place less emphasis on mindfulness practice. As a result, it is unclear whether and to what extent the benefits resu lting from these therapies can attributed to mindfulness. Similarly, although mindfulness res earchers give anecdotal accounts of changes in participants attitudes toward themselves and their suffering, questions remain about the mechanisms by which mindfulness might lead to reductions in disordered eating behavior. Several mechanisms have been proposed base d on existing models, but few studies have specifically examined whether these proposed m echanisms mediated the relationship between mindfulness and disordered eating. Present Research Several questions have em erged that inform this investigation. In the midst of the increasing literature on the use of mindfulness interventions to ta rget eating disorders symptoms, it has become necessary to better understand the mechanisms by which mindfulness fosters improvements in disordered eating. Doing so ma y lead to more powerful strategies for both prevention and treatment. This approach comple ments an existing theme in the eating disorders prevention literature in which res earchers have attempted to identif y personal qualities and skills that may increase resilience and reduce vulnerability both to disordered eating and a range of
42 other social and psychological di fficulties (Irving, 1999; Levine & Smolak, 2006). Such skills may be particularly important to individuals who are somewhat vulnerable because of underlying psychological characteristics such as perfectionism. The present st udy consists of two parts, and was designed to help address these issues by investigating self-c ompassion as a possible mechanism by which mindfulness re lates to lower levels of symptomatology, as a possible link between maladaptive perfectionism and disordered eating, and as a possible component of eating disorders prevention. Rationale for Study 1 The f irst study in the current research is de signed to investigate the relationships among mindfulness, self-compassion, perfectionism, and disordered eating within a sample of university students. While some of these relationships ar e well-established (i.e. the relationship between perfectionism and disordered eating), no study to date has looked simultane ously at all of these constructs. Establishing the di rection and strength of the relationships among these constructs may provide important guidance for the de velopment of eating disorders prevention programming. Similarly, this study aims to investigate self-compassion as a possible mechanism through which mindfulness may be related to disordered eating, and as a mediator in the relationship between maladaptive perf ectionism and disordered eating. Hypotheses for Study 1 1. Mindf ulness will be positively correlated w ith self-compassion and negatively correlated with maladaptive perfectionism and with disordered eating. 2. Self-compassion will mediate the relationship between mindfulness and disordered eating. Specifically, mindfulness will be related to high er levels of self-compassion, which will be related to lower levels of disordered eating. 3. Self-compassion will mediate the relationship between maladaptive perfectionism and disordered eating. Maladaptive perfectionism will be related to lower levels of selfcompassion, which will be related to hi gher levels of disordered eating.
43 4. The mediation model involving maladap tive perfectionism, self-compassion, and disordered eating will be moderated by gender. Specifically, it is expected that selfcompassion will be more strongly related to disordered eating for women than for men. 5. The strength of this relations hip will also be moderated by body image investment such that self-compassion will be more strongly rela ted to disordered eating when individuals report a high level of body image investment. Exploratory Analyses: If hypothesis # 3 is supported and self-com passion mediates the relationship between maladaptive perfectionism and disordered eating, a multiple mediation model will be examined to determine whether self-compassion continues to account for a significant indirect effect when self-esteem is also examined. This is based on research indicating that self-compassion is a related but distinct construct from self-esteem and may constitute a healthier self-stance (Neff & Vonk, 2009). Self-esteem will also be examined as a possible moderator in this model, as selfcompassion has been theorized to be most relevant when self-esteem is low. Rationale for Study 2 Study two is designed to inve stigate the integration of self-compassion into eating disorders prevention programm ing. Specifically, this study aims to determine whether a one hour self-compassion workshop can significantly increase self -compassion in college women who may be vulnerable to devel oping eating disorders. To date, many studies measuring selfcompassion have investigated the construct within the context of longer term interventions such as Mindfulness Based Stress Reduction or Compa ssionate Mind Training. These approaches have proven effective but have some notable limit ations. First, these interventions require a significant time commitment both to clinicians and participants. This can make it difficult to reach large numbers of students, both because of limitations of staff resources and because students may be reluctant to commit to a long term intervention unless they are already in considerable distress. As many university counseling centers utilize primarily short term
44 (including single session) outreach models for prevention programming (i.e. Mann et al., 1997), the present study seeks to integrate self-compassion in to an outreach format that might be easily utilized in a univers ity counseling center. Hypothesis for Part 2 Self-com passion scores are expected to be significantly higher after a one hour self-compassion workshop than before. This is ba sed on previous studies th at have successfully modified levels of self-compassion (Shapiro et al ., 2005; Shapiro et al., 2007) It is important to note that these studies have measured self-c ompassion scores before and after an 8-week mindfulness-based intervention. Be cause of the differences in inte rvention formats, it is difficult to extrapolate the expected magnitude of effect fr om previous research. It could reasonably be expected that effect sizes would be relatively small, given the br iefer nature of the intervention. However, it is also possible that effect sizes w ould be larger than in past research, as this intervention is directly target ed at self-compassion rather th an indirectly affecting selfcompassion through mindfulness practice. Effect size estimates, as well as patterns of change for individual participants, we re therefore included as exploratory analyses.
45 CHAPTER 3 METHODS AND MATERIALS The curren t chapter describes two studies investigating the role of self-compassion in college student mental health. The first study examines the relationships among selfcompassion, mindfulness, maladaptive perfectioni sm, and disordered eating in a sample of undergraduate women, including the possible me diating role of self-compassion in the relationship between maladaptive perfectionism and disordered eating. The second study was designed to investigate the us e of a single session self-com passion workshop that can be implemented in a university counseling center. Study 1 Participants Participants were undergraduate students attendin g a large, public university in the southeastern United States. Participants we re recruited through va rious courses in the psychology departm ent and were of fered course credit for their participation in this study. Participants were provided with a link to a website containing an informed consent form and a brief description of the study. Participan ts indicated their consent by checking a box electronically and typing their na me. Participants names were r ecorded only for the purpose of course credit and were deleted from the dataset prior to analysis. One hundred eighty one students consented to the study. Eight participants were missing more than 25% of responses and were excluded from further analysis. The final sample for this study included 173 participants (105 women, 68 men), ranging in age from 18 to 27 (M = 19.09; SD = 1.56). Most participants were in thei r first (46.8%) or second (28.9%) of undergraduate studies. The racial/ethnic breakdown of the sample was as follows: 11.6% African American, 12.1% Asian-Americans, 59% Caucasian, 12.7% Hispanic/Latino, .6% Native American, 4%
46 multiracial. This breakdown is similar to th at of the overall full-time undergraduate student population at the university these students attended. Approximately 10% of participants reported that they had sought treatment for eating, weight or body image concerns at some point in the past, and four of these participan ts (2.3%) indicated that they were currently in treatment. All participants were treated in accordance with the E thical Principles of Psychologists and Code of Conduct (American Psychological Association, 2002). Measures Perfectionis m: The Almost Perfect Scale-Revise d (APS-R) was used to assess perfectionism. The APS-R was developed by Slaney et al. (2001) and consists of 24 items across three subscales: High Standards, Discrepancy, an d Order. Individuals respond to items using a 7-point Likert scale ranging from 1 strongly disagree to 7 strongly agree. The APS-R has shown evidence of high internal consistency in a college student sample, with Cronbachs alphas ranging from .82 for the High Standards subscale to .92 for the Discrepancy subscale (Slaney et al.). The subscales relate in expected directions with other measures of perfectionism. The Discrepancy subscale, of particular interest to this study, was designed to measure the perceived discrepancy between an individua ls expectations and performan ce. Example items include I am not satisfied even when I know I have done my best, and I often feel frustrated because I cant meet my goals. It has been shown to tap into aspects of perf ectionism described as maladaptive. For instance, Discrepancy scores have been negatively related to self-esteem and positively related to depres sion (Rice, Ashby, & Slaney, 1998). According to a classification system created and validated by Rice and Ashby (2007), elevated scores on the High Standards subscale can be used to classify an individual as a perfectionist, while elevated scores on both the High Standards and Discrepancy subscales ar e indicative of maladaptive perfectionism.
47 Disordered Eating: The Eating Attitudes Test (EAT; Garner & Garfinkel, 1979) was used to assess disordered eating. The EAT was originally developed to detect symptoms of anorexia nervosa and consisted of 40 self-report items. After further examination, the authors concluded that 14 of the origin al items yielded redundant inform ation and created a shortened version of the scale (EAT-26) that retained ma ny of the psychometric properties of the original measure (Garner, Ohlmstead, Bohr, & Garfinkel, 1982) and consisted of three subscales: dieting behavior, oral control, food preoccupation. The EAT-26 is now one of the most widely used self-report eating disorder measures (Mintz & OHalloran, 2000). Each subscale has shown adequate internal consistency in a sample of college women ( = .60 to =.88; Tylka & Wilcox, 2006), and the full measure has demonstrated three week test-retest reliability of r = .80 (Mazzeo, 1999). Although the instrument was originally deve loped exclusively for the detection of anorexia nervosa, diagnostic criteria and nomenclature have changed significantly since its development. Evidence now suggests that the EAT-26 may now be most appropriately used to distinguish individuals with a ny diagnosable DSM-IV eating diso rder from individuals without any disorder (Mintz & Holloran). For instance, while scores cannot relia bly distinguish between individuals with anorexia nervos a and bulimia nervosa, scores can distinguish individuals with either disorder from healthy controls (Garfi nkel & Newman, 2001). Scores on the EAT-26 have also been used to differentiate among individuals with varying leve ls of eating disorder symptomatology (e.g., full vs. partial syndrome), s uggesting that the EAT-26 may be useful as a continuous measure of disordered eating. In addition to approximating the severity of an existing set of eating disorder symptoms, scores on the EAT-26 have been used to predict weight maintenance following recovery from an eati ng disorder while high scores have been
48 significantly related to later rehospitalization (O rbitello et al., 2006). Although it was designed to contain three subscales, the total score is mo st commonly used in the literature. Items are rated on a six-point Likert scale ranging from never to always Example items include I avoid eating when Im hungry, and I am preoccupied by a desire to be thi nner. In scoring the instrument, responses of never, rarely, and sometimes receive a score of zero, while responses of often, usually, and always re ceive scores of one, two, and three respectively. A cutoff score of 20 is generally thought to indicate the presence of an eating disorder. Mindfulness: Mindfulness was measured using the short form of the Freiburg Mindfulness Inventory (FMI; Buch held et al., 2001). The FMI was initially designed to measure mindfulness as either a target va riable of clinical interventions, as a moderating variable or as a personality trait (Buchheld et al). The original instrument contained 30 items measuring a unidimensional mindfulness construct, and was deve loped for use with experienced meditators. The authors later developed a s hort form of 14 items that was appropriate for use with the general population (those without meditation experience) and with clinical samples. The short form has shown evidence of high internal consistency ( = .86) and of retaining its psychometric properties across diverse samples of individu als with and without meditation experience (Walach, Buchheld, Buttenmuller, Kleinknecht, & Schmidt, 2006). This scale was based on a conceptualization of mindfulness as made up a cognitive component, a process component, a component related to the acceptance of experience, and one that relates to a nonjudgmental stance. Unlike some representations of the mind fulness construct that involve distinct facets, these components are thought to be intimately interrelated, such that the most appropriate way to view mindfulness is holistically. Example items include I feel connected to my experience in the here-and-now and I accept unpleasant experi ences. Items are rated on a 4-point Likert-
49 type scale from 1 rarely to 4 almost always. Higher scores are indicative of higher levels of mindfulness. Scores on this instrument have been shown to increase significantly over the course of a mindfulness retreat and to distinguish meditating from non-meditating populations (Walach et al., 2006). Scores on this instrument correlate positively w ith measures of selfawareness and negatively with meas ures of psychological distress. Self-Compassion: Self-Compassion was measured us ing the Self-C ompassion Scale (SCS; Neff, 2003a). The SCS was designed to meas ure an individuals tendency to be kind to oneself in instances of pain or failure, to percei ve ones experience as part of the larger human experience, and to hold thoughts and emotions in ba lanced awareness. The 26 items of this scale compose six interrelated factors. Res ponses to each item range from 1 almost never to 5 almost always. Subscale means are calculated for each factor, and these six means are summed to create a total score. Higher scores are indicative of higher levels of self-compassion. The SCS has shown evidence of ad equate internal consistency in a college student sample ( = .92; Neff) and evidence of good construct validit y, including discriminate validity with other measures of self-attitudes. Scores remained re latively stable over a three week time period, with test-retest reliability of r = .93. As would be expected, scor es on this measure are moderately correlated with but distinct from self-esteem. Sample items include When Im going through a hard time, I give myself the ca ring and tenderness I n eed, and Im tolerant of my own flaws and inadequacies. Scores predict additional variance in outcome measures (such as selfrumination and anger) after self-esteem is acc ounted for (Neff & Vonk, 2009). Scores on this measure have been negatively related to meas ures of depression and anxiety and positively related to various aspects of positive functioning such as problem focused coping and life satisfaction (Neff, 2003a; Neff, Ki rkpatrick, & Dejitthirat, 2004).
50 Body Image Investment: The Self Evaluative Salienc e subscale of the Appearance Schemas Inventory-Revised (ASI-R; Cash et al., 2004) was used to assess participants investment in their appearance. The ASI-R consis ts of twenty items and contains two subscales: Self evaluative salience (SES), which assesses the extent to which individu als define themselves by their physical appearance, and motivational salience (MS), which assesses the extent to which individuals engage in appearance-management behavi ors. High total scores are reflective of an individual who believes that the physical appearance is a centrally defining feature of the self. Example items include When I see good looking people, I wonder about how my own looks measure up. Participants re spond to these items on a 5-point Likert scale ranging from 1 strongly disagree to 5 strongly agree. Scores on this measure relate to greater internalization of thin ideal media messages and greater levels of body image disturbance (Ip & Jarry, 2007). The SES subscale te nds to be more strongly rela ted than the MS subscale to disturbance and psychopathology. Convergent validity has been established by strong positive correlations with body image disturbance, perfectio nistic self-presentation, and disordered eating attitudes (Cash, 2003). Cash et al (2004) reported adequate internal consistency for the entire measure ( = 0.88), the SES subscale ( = .82) and the MS subscale ( = .90) in a sample of college women. Self-Esteem: The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) was used to measure self-esteem. The RSES consists of te n statements which partic ipants rate on a scale ranging from 1 strongly disagree to 4 strongly agree. Total scores on this measure can range from 10 to 40, with higher scores are indica tive of more favorable self-appraisals. Items include On the whole, I am satisfi ed with myself, and I am able to do things as well as most other people. The RSES has been assessed as a valid measure of e xperienced self-esteem
51 (Demo, 1985) and has shown eviden ce of reliability and validity in a college student population. For instance, Tylka and Subich (2004) reported an internal consistency reliability of =.93 in a sample of college women and Robinson and Shaver (1973) found a three week test-retest reliability of r = .85 in a sample of college students. Social Desirability: Because this study used an excl usively self-report format, an abbreviated version of the Marl owe-Crowne Social Desirability Scale (MCSDS) was included in this study. The original MCSDS was develope d by Crowne and Marlowe (1960) and uses a series of true/false items to de tect the tendency to respond in a so cially desirable manner. Items were derived from existing personality assessments, and were thought to re flect attributes that were socially desirable but unlikely to occur. As a result, high scores are sometimes thought to be indicative of faking good (Loo & Thorpe, 2000). Example items include No matter who Im talking to, Im always a good listener, and I am always courteous, even to people who are disagreeable. Reynolds (1982) developed a 13-item short version of the scale that is strongly correlated with the original vers ion (r = .93) and has demonstrated adequate internal consistency ( = .76) in a sample of college students. Procedure Participan ts accessed the study website through a link provided by course instructors or through an electronic listing of a ll studies available for course credit. Before completing any study questionnaires, participants were provided with an electr onic informed consent form. After indicating their agreement and typing thei r name (for the sake of course credit), participants were directed to th e first page of survey questions. The items were presented in the same order for all participants. In addition to the vari ables of interest, tw o additional measures were included to help disguise the purpose of this study. Measures were presented in the following order: Almost Perfect Scale Revised (APS-R), Rosenburg Self-Esteem Scale (RSES),
52 Psychological Well-Being Scales (PWBS; Ryff & Keyes, 1995), Freiburg Mindfulness Inventory (FMI), Self-Compassion Scale (SCS), Marlowe-Cr owne Social Desirability Scale (MCSDS), Experiences in Close Relations hips Questionnaire Revised (ECRR; Fraley, Waller, & Brennan, 2000), Appearance Schemas Inventory Revised (ASI-R), Eating Attitudes Test (EAT-26). Demographics questions were incl uded at the end of the survey. All questions were answered electronically, and answers were stored separately from participants identifying information so that responses to the scales could not be ma tched to individual participants. Surveys took approximately 30-45 minutes to complete. Partic ipants were provided with contact information for mental health agencies on campus, in the even t that they experienced any distress as a result of responding to survey questions. Study 2 Participants Participants for this study were fem ale students attending a la rge, public university in the southwestern United States. Participants were recruited from two si ngle-session self-compassion workshops conducted through the uni versity counseling center. Workshops were offered for free and available to all current students. Students we re not required to consent to the study in order to attend the workshops. While workshops were advertised broadly thro ughout the university student body, most workshop attendees report ed being referred by a current clinician. In all, eight female stude nts attended one of two self -compassion workshops. All students who attended the workshops opted to part icipate in the study. Part icipants ranged in age from 18 to 27 (M = 21.5; SD = 3.38). Slightly more than half of participants were in their first (25%), second (25%), or third (12.5%) year of undergraduate studi es and the remaining 37.5% of participants identified themselves as graduate or professional student s. The racial/ethnic breakdown of the sample was as follows: 62.5% Caucasian, 25% Hispanic/Latino, 12.5% Native
53 American. The percentage of racial/ethnic minor ity students in this sample approximates the percentage of racial/ethnic minority student s in the university th e students attend. Two participants (25%) had previously sought treatment for eating, weight, or body image concerns, and one was still in tr eatment for related concerns. Procedure Description of self-compassion workshop A one-hour workshop titled Quiet Your Inne r Critic was created sp ecifically for the second portion of this study. Quiet Your Inner Critic was designed to introduce students to the concept of self-com passion, provide an opportunity for students to explore the role of selfcriticism and self-compassion in creating/maintaining suffering, and give students tools for fostering self-compassion in their everyday live s. The workshop consisted of the following components: 1. Introductory didactic material, including examples of critical and compassionate self-talk, myths and facts about the effects of self-compassion, and characteristics of a compassionate response (Neff, 2003b) 2. Two short writing exercises in which students fi rst wrote about their affective response to a perceived failure or flaw and later returned and responded from the point of view of a perfectly compassionate friend. This exercise was adapted from the exercise described by Neff (2008) and is described in full in Appendix M. 3. Brief compassion meditation, in which participan ts first generate a feeling of compassion for someone else and then focus on themselves. This exercise was chosen because of the established link between mindfulness practice and self-compassion (Neff, 2008; Shapiro et al., 2007). Full text of the meditation used in the workshop can be found in Appendix N. 4. Processing and discussion Participants were also provided with handouts de signed to give them tools to further cultivate self-compassion. Handouts included a more detailed set of instructions for the compassionate writing exercise, instructions for the self-compassion meditation, and a list of resources for more information.
54 Advertising and recruitment The workshop was offered twice during the spring semester, once at the university counseling center and once at th e student union. Workshops were advertised along with other available therapy groups and workshops offere d through the university counseling center. Additionally, fliers were distribut ed at the campus health center, at outreach events targeting Panhellenic organizations, and at Body Pride Week events. Clinicians at the counseling center were also able to refer current clients to the workshops as an adjunct to therapy, and were encouraged to refer any client s who struggle with perfectionism self-criticism, or low selfesteem (rather than clients specifically exhibiti ng eating disorders symptoms). This recruitment strategy was designed to approxima te typical strategies used to advertise counseling center workshops, while also targeting student populations that may be at increased risk for disordered eating attitudes. Data collection Workshop attendees were inform ed of the study at the beginning of the hour-long workshop. Students were informed that the inves tigator was collecting data designed to inform future preventative outreach programming, and th at their participation in the study would not impact their ability to participat e in the remainder of the works hop. Students were also informed that all responses would be ke pt confidential, that their informed consent would be kept separately from any survey responses, and that preand postworkshop responses would be linked to one another only through a code number. Workshop atte ndees were then provided with an informed consent form and a copy of pre-te st measures, which included a demographic form, the SCS (Neff, 2003a), the APS-R (Slaney et al ., 2001), the EAT-26 (Garner & Garfinkel, 1979), and the RSES (Rosenberg, 1965). Informed consen t forms and pre-test measures were collected and kept separately for the duration of the wo rkshop. Following the workshop, participants were
55 provided with a post-test survey. To minimi ze the burden on participants and maximize time spent in intervention, post-test data colle ction was limited to the SCS (Neff).
56 CHAPTER 4 RESULTS Study 1 Descriptive Statistics a nd Preliminary Analyses Means and standard deviations for all variable s of interest are presented in Table 4-1. Internal consistency reliability coefficients were calculated for each variab le and are included in Table 4-1. Of the measures used in this st udy, the Marlowe-Crowne Social Desirability Scale had the lowest internal consistency (KR-20 = .69). This result is similar to that found in other college student samples (see Barger, 2002 for a review ). Cronbachs coeffi cients alpha for other measures ranged from .81 (FMI) to .94 (APSR Discrepancy), provi ding evidence of high internal consistency. Standardized skewness and kurtosis values were examined and were within acceptable limits (z < 2.56, p < .01) for all measures except the EAT-26. The EAT-26 distribution was significan tly positively skewed ( z = 5.36) and slightly kurtotic ( z = 2.84). This is similar to distributions found in other studies using this measur e, and is unsurprising given the scoring of the measure and the low base rate of the behaviors it measures. Recall that participants respond to items usi ng a six point Likert scale, bu t the first three responses all receive scores of zero. This enables the m easure to more accurately differentiate between normative behaviors and disordered eating, but results in a larger number of cases clustered at low values. In this sample, as would be expect ed, the vast majority of cases fell well below the clinical cutpoint of for a total score (the median score in this sample was ), while a few students reported elevated levels of disordered eating behavior and received much higher scores. To determine whether this skew adversely affected study results, a square root transformation was used with this variable, and all models were run twice, once with raw scores and once with transformed scores. Relationships among variable s remained consistent in direction and very
57 similar in strength, with the same mediating and moderating effects emerging as significant. In light of this consistency, raw sc ores were reported in this sect ion, as these can be more easily interpreted based on familiar sc oring and past research. To further assess the normality of the distribution, data were examined for univariate outliers. One potential outlier was identified due to highly el evated scores on the EAT-26. Examination of other responses from this partic ipant indicated that the high elevation was likely not an error, and instead represented the typical distribution of scores on that measure. After determining that relationships among scores were not noticeably di fferent without this participants data, the data were retained in th e analyses. The data were also examined for possible multivariate outliers using Mahalanobis distance. No participants scores exceeded the critical chi square for this model (20.52), so all participants remained in the analyses. Because most study analyses were based on multiple regression, regression assumptions were examined on the variables in this study. In addition to requiring quanti tative or categorical variables with nonzero variance, regression require s that predictor variables are not perfectly multicollinear. To examine this assumption, P earson correlations, tolerance and VIF statistics were examined. Tolerance values were all abov e .4 (ranging from .49 to .61) and VIF statistics were all close to 1 (ranging from 1.6 to 2.0). It was determined that multicollinearity was not likely to be a problem for variables in this mode l. Visual inspection of residual scatterplots indicated that error terms were relatively normally distributed. A Durbin Watson test statistic close to 2.0 (1.89 in this model) indicated that error terms were not highly correlated with one another. These assumptions support the generali zability of the findings from regression models in this study.
58 Because of expected gender differences on many variables of interest, means and standard deviations were calculated separately for men and women in the study. A multivariate analysis of variance (MANOVA) was conducted to determine whether men and women responded differently in the current study. Follow up univariate ANOVAs were then conducted to further explore these differen ces. One relevant variable, Body Image Investment, violated the homogeneity of variance assumption. Welchs F is reported for this variable. Results confirmed significant gender differences on study variables, Wilks = .847, F (8, 163) = 3.674, p = .001. Univariate ANOVAs revealed that women scored significantly high er than men on Discrepancy, F (1, 170) = 13.07, p < .001, d = .55; Self-Compassion, F (1, 170) = 8.088, p = .005, d = .42; Body Image Investment, F (1, 170) = 9.924, p = .002, d = .48; and Disordered Eating, F (1, 170) = 7.139, p = .008, d = .41, while men scored significantly higher than women on Self-Esteem, F (1, 170) = 5.61, p = .019, d = .36. Effect size estimates indicate that these gender differences are in the medium to large range (Cohen, 1992). Pearson correlations were calculated for a ll pairs of variab les, and are presented in Table 4-2. Again, these correlations were calculated separately for men and women in the study. Correlations for the subscales of the APS-R were in expected dire ctions and generally consistent with findings of past research. For example, both men and wome n had Discrepancy scores that showed large negative correlati ons with Self-Esteem scores ( r = -.74 and r = -.56). As hypothesized, mindfulness was positively re lated to self-compassion for men (r =.50) and women ( r = .66), demonstrating a large effect size for both. Mindfulness was negatively related to maladaptive perfectionism (measur ed by the APS-R Discrepancy scale; r = -.34) and disordered eating ( r = -.25) in women, both with a medi um effect size. However, both correlations were small and nonsignificant (p > .05) in men. It is notab le that social desirability
59 (measured by the MCSDS) showed a small to medi um significant relationship with all measured variables in women (ranging from r = .21 for Discrepancy to r = .38 for Body Image Investment). Relationships with study variables were generally weaker and nonsignificant in men, with the exception of a me dium significant relationship w ith Body Image Investment ( r = .34). Because social desirability was significan tly correlated with several other measured variables, the MCSDS total score was entered as a covariate in all models in this study1. Self-Compassion as Mediator Previous research has focused on self-com passion as a mechanism through which mindfulness-based interventions work. To de termine whether this conceptualization was supported by current data, a mediation model was examined with self-compassion as the mediator of the relationship betw een mindfulness and disordered eating. Results are presented in Table 4-3. In this model, mindfulness explai ned significant variance in disordered eating, B = -.242, t (169) = -2.13, p = .035, and in self-compassion, B = .250, t (169) = 9.40, p < .001. Self-compassion also explained signif icant variance in disordered eating, B = -.772, t (169) = -2.38, p = .019. When both self-compassion and mindfulness were entered into the model, the relationship between mindfulne ss and disordered eating was reduced to nonsignificance, B = -.048, t (169) = -.349, p = .727. Bootstrapping was used to confirm the presence of an indirect effect. This techni que is preferred by many (Preacher & Hayes, 2004; Shrout & Bolger, 2002) when examining mediat ion models because it takes into account the actual distribution of indirect e ffects. Other commonly used test s of mediation (such as Sobels test) assume a normal distribution of indirect e ffects, and may have less power to detect an 1Some researchers recommend against th is practice on statistical and conc eptual grounds (see Barger, 2002 for discussion), yet it remains common practice in self-report res earch. To account for this, an alyses were run both with and without a covariate, yielding comparable results. Results calculated without a covariate are available upon request.
60 effect. In this study, 1000 bootstrap samples were created, yielding a 95% confidence interval of -.3563 to -.0655 around the indirect effect. As this interval did not include results indicated the presence of a significant indirect effect. Maladaptive perfectionism, self-c o mpassion, and disordered eating To examine the role of self-com passion in the relationship between maladaptive perfectionism and disordered eating, a simple mediation model was first examined. Results indicated that maladaptive pe rfectionism (measured by the APS-R Discrepancy subscale) explained significant varian ce in disordered eating, B = .168, t (169) = 3.52, p < .001, and in selfcompassion, B = -.091, t (169) = 7.43, p < .001. However, self-compassion failed to account for significant variance in disordered eating, B = .508, t (169) = -1.70, p = .090. When both selfcompassion and maladaptive perfectionism were en tered into the model, the relationship between maladaptive perfectionism and disordered eating remained significant, B = .122, t (169) = 2.22, p = .028. However, bootstrapping using 1000 bootstra p samples resulted in a 95% confidence interval of .015 to .120 around the indirect effect. This indica tes that although full mediation was not supported, a significant amount of the va riance shared by malada ptive perfectionism and disordered eating was explained by self-compa ssion. This provides evidence for partial mediation, indicating that the e ffect of maladaptive perfectio nism on disordered eating may occur in part through a direct route and in part through the effect of self-compassion. To further explore conditions that may infl uence the presence of an indirect effect, several moderated mediation models were examined. Moderated mediation: Gender Because of the estab lished gender differences in both self-compassion and disordered eating (see Tables 4-1 and 4-2) a moderated mediation model was examined to determine whether the indirect effect through self-compassion was mode rated by participants gender
61 (coded as for males and for females in this analysis). Moderated mediation is useful in determining whether an established mediation effect remains constant across groups or at different levels of a variable. The path from th e independent variable to the mediator, from the mediator to the dependent variable, or both, may be influenced by the level of a fourth variable. Variables were entered into an SPSS macro cr eated by Preacher, Rucker, and Hayes (2007), designed to detect conditional indi rect effects. This macro allo ws the researcher to indicate which path(s) may be affected by the moderating va riable. In this case, it was hypothesized that some of the effect of malada ptive perfectionism would be ca rried through self-compassion, but that the extent to which this would in turn influence disordered eating would differ based on gender. This hypothesis was based on research and theory indicating that sociocultural factors may predispose women to eating disorders more than men (Mussell, Binford, & Fulkerson, 2000). To test the moderated mediation hypothesi s, a moderation effect is first tested to determine whether the interaction between th e mediator and proposed moderator explains additional variance in the dependent variable. Next, the strength a nd significance of the indirect effect (the amount of variance that is carried th rough the mediating variable) is tested at different levels of the moderating variable. Results indicated the product term created by self-compassion and gender did not explain significan t additional variance in the model, B = -.477, t (169) = -.90, p = .368. To determine whether the indirect effect (the effect of mala daptive perfectionism on disordered eating through self-com passion) was moderated by gender, the strength of the indirect effect was examined at both possible levels of th e moderator. For males in this sample, normal theory tests indicated that the indirect effect through self-c ompassion was clea rly nonsignificant ( p = .634). However, when gender was set to fem ale, normal theory tests indicated that the indirect effect through self-com passion approached significance (p = .065).
62 To further probe this result, a simple mediation model was run on only females in the sample. This analysis supported th e existence of an indirect effect for female participants. In this model, maladaptive perfectionism accounted for significant variance in self-compassion, B = -.090, t (169) = -5.42, p < .001 and marginally significant variance in disordered eating, B = .126, t (169) = 1.97, p = .052. Additionally, self-compassion accounted for marginally significant variance in disordered eating, B = -.726, t (169) = -1.89, p = .061. When both self-compassion and maladaptive perfectionism were entered into the model, the relationship between maladaptive perfectionism and disordered eating was reduced to nonsignificance, B = .061, t (169) = .851, p = .397. Bootstrapping results confirmed th e significance of the indirect effect. One thousand bootstrap samples produced a 95% confidence interval of .0119 to .1481 around the indirect effect. This indicates that, for fe male participants there was a significant indirect effect of maladaptive perfectionism on di sordered eating thro ugh self-compassion. Moderated mediation: Body image investment To determ ine whether the indirect effect for female participants was moderated by levels of body image investment, another moderated medi ation model was examined. In this model, body image investment was hypothesized as the modera tor, such that the i ndirect effect through self-compassion was expected to be larger for wo men at higher levels of body image investment. To examine this model, scores on maladaptive perfectionism, self-compassion, disordered eating, and body image investment, for female particip ants only, were entered into the SPSS macro described above. Results indicated that the product term created by self-compassion and body image investment did not account for additional variance in the model, B = -.528, t (101) = 1.189, p = .237. In examining the strength of the i ndirect effect at various levels of the moderator, the indirect effect remained nonsignificant at mean levels of body image investment
63 ( p = .292) as well as one standard deviation above ( p = .213) and below ( p = .929). The hypothesis that body image investment would modera te the indirect eff ect was not supported. Exploratory Analyses: Self-C ompassion vs. Self-Esteem Multiple mediation Previous research on perfectionism and undesirable mental health outcomes has focused on the mediating effects of self-esteem (i.e. Rice et al., 1998). In order to determine whether the indirect effect through self-compassion found in the preceding analyses could be better accounted for by self-esteem, a multiple mediat ion model was entered into an SPSS macro created by Preacher and Hayes (2008) that was designed to simultaneously investigate the multiple mediators. This model examined the indirect effect of maladaptive perfectionism on disordered eating through both se lf-compassion and self-e steem. Consistent with the bivariate correlations calculated previously (Table 42), maladaptive perfectionism accounted for significant variance in both self-esteem, B = -.188, t (101) = -6.168, p < .001, and selfcompassion, B = .090, t (101) = -5.424, p < .001, as well as marginally significant variance in disordered eating, B = .126, t (101) = 1.971, p = .052. However, when both variables were entered as potential mediators, neither one alone accounted for significant variance in disordered eating, self-compassion: B = -.615, t (100) = -1.521, p = .132; self-esteem: B = -.190, t (100) = .866, p = .389, but the direct effect from mala daptive perfectionism was reduced to nonsignificance, B = .036, t (100) = .456, p = .650. Bootstrapping with 1000 bootstrapped samples was used to create confidence interv als around each indirect e ffect. Bootstrapping techniques resulted in a 95% confidence interv al of -.032 to .124 around th e indirect effect for self-esteem, and a 95% confidence interval of .003 to .132 around the indirect effect for selfcompassion. Put simply, this indicates that when both variables are examined simultaneously as mediators, self-compassion continues to account fo r a significant indirect effect, while self-
64 esteem does not. These results are consistent with the proposition that self-compassion better accounts for the relationship between maladaptive perfectionism and disordered eating in women than self-esteem. Moderated mediation: self-esteem as moderator The final set of analyses for this study exam ined whether self-esteem moderated the indirect effect of maladap tive perfectionism on disordered eating through self-compassion. Previous literature has suggested that self-compassion may be es pecially relevant when selfesteem is low (Leary et al., 2007). Accordingly, it was hypothesized that the indirect effect of maladaptive perfectionism on disordered eati ng through self-compassion would be stronger in participants who scored lower on measures of self-esteem. To explore this hypothesis, a moderated mediation model was analyzed. Results indicated that the interaction between selfesteem and self-compassion did not account for significant additional variance in disordered eating, B = .081, t (101) = 1.570, p = .120. However, the strength of the indirect effect did differ at varying levels of the moderator. Conditional indi rect effects were calculated at mean levels of the self-esteem, as well as one standard deviation above and below the mean. Results indicated that the indirect effect through self-compassion is significant when self-esteem is one standard deviation below the mean ( p = .042), marginally significant when it is at the mean ( p = .057), and nonsignificant when self-esteem is one standard deviation above the mean ( p = .466). In general, the indirect effect th rough self-compassion was weaker at higher levels of self-esteem, to the point of being nonsignificant at high levels of self-esteem. This lends support to the hypothesis that self-compassion is more relevant when self-esteem is low. In summary, the results of Study 1 conf irmed many of the research hypotheses. Bivariate correlations revealed that mindfulness was positively related to self-compassion and negatively related to both maladaptive perf ectionism and disordered eating. Two simple mediation models
65 indicated that self-compassion acted as a mediator between maladaptive perfectionism and disordered eating, and a partial mediator betw een maladaptive perfectio nism and disordered eating. This partial mediation model was modera ted by gender, in that there was a significant indirect effect for women but not for men. However, the mediation model was not moderated by body image investment. A multiple mediation m odel further supported the importance of selfcompassion, as it remained a sign ificant mediator even when se lf-esteem was included in the model. The final moderated mediation mode l indicated that, for women, self-compassion partially mediated the relationship between maladaptive perfectionism and disordered eating, with a stronger indirect effect em erging for women with low self-esteem. Study 2 Descriptive Statistics a nd Preliminary Analyses Means and standard deviations were calculate d f or all pretest variables and are displayed in Table 4-4. Visual inspection of scale mean s revealed that pretest scale means approximated those found in the larger (Study 1) sample. To confirm this, the eight participants from Study 2 were compared to a sample from Study 1 ma tched approximately on age, race, and sexual orientation. Because of the small sample size in the following analyses, nonparametric statistics were used to assess differences between sample s. Nonparametric tests are preferred when parametric assumptions (such as normality of data and homogeneity of variance) are in question (Field, 2005). In this case, a series of Mann-Wh itney U tests indicated that the matched samples did not differ from one another on SCS, U = 24, p = .40; RSES, U = 31, p = .92; EAT-26, U = 25, p = .46; or the Discrepanc y subscale of the APS-R, U = 19, p = .17. Internal consistency reliability was calculated for all measures and can be found in Table 4-4. Internal consistency was fairly low for the EAT-26, though comparab le to other college student samples ( = .57) and high for the SCS ( = .91), RSES ( = .86), and Discrepancy scale of the APS-R ( = .97).
66 Treatment Effects It was hypothesized that particip ants would experience a signifi cant increase in levels of self-com passion from the preto posttest. A Wilcoxon signed-rank test was used to determine whether participants levels of self-compassion changed signifi cantly over the course of the workshop. Results indicated th at the hypothesis was supported in that participants scored significantly higher on self-com passion after the workshop ( Mdn = 16.475) than before the workshop, ( Mdn = 16.05), z = 2.033, p <.05. Effect size estimates indicate that the magnitude of this difference was large ( r = .51). Because this statistical an alysis was based on relative ranks rather than exact scores, a large effect in this case indicates that most individual participants scored higher after the workshop than before. Individual participants preand posttest scores are plotted in Figure 4-1.
67 Table 4-1. Internal Consistency, Means, and Standard Deviations of Study 1 Variables Measure Men (n = 68) M SD Women (n = 105) M SD APS-R Discrepancy* FMI SCS* RSES* ASI (SES subscale)* EAT-26* MCSDS .94 .81 .92 .90 .84 .87 .69 36.29 13.32 38.81 5.77 14.03 2.55 32.58 5.14 3.11 0.54 7.14 8.79 5.60 2.54 44.07 14.79 38.48 6.75 12.89 2.85 30.67 5.46 3.41 0.68 10.92 9.60 5.61 3.03 Indicates differences between men and women are significant p<.05.
68 Table 4-2. Pearson Correlati ons Between Study 1 Variables HS ORDER DISC FMI SCS RSES ASI(SES) EAT-26 MCSDS HS ORDER DISC FMI SCS RSES ASI (SES) EAT-26 MCSDS 1 .384* .090 .192* .005 .346* .044 .008 .139 .537* 1 .044 .197* .039 .188 -.055 .014 .266* -.227 -.209 1 -.336* -.510* -.561* .444* .246* -.213* .280* .165 -.424 1 .663* .537* -.433* -.247* .250* .212 .234 -.445* .500* 1 .541* -.476* -.308* .327* .458* .354* -.739* .503* .647* 1 -.426* -.285* .349* .224 .161 .106 -.063 -.306* -.120 1 .450* -.385* -.178 .036 .259* -.095 -.143 -.285* .251* 1 -.218* .048 .133 -.048 .037 .280 .113 -.344* -.126 1 Correlations above the diagonal = women; Correlations below the diagonal = men Indicates significant correlation ( p<.05)
69 Table 4-3. Self-Compassion as Mediator Be tween Mindfulness and Disordered Eating Path B SE p FMI to EAT-26 (c path) FMI to SCS SCS to EAT-26 FMI to EAT-26 (c path) -.242 .250 -.772 -.048 .114 .027 .325 .138 -.163 .571 -.228 -.032 .035 <.001 .019 .167 Note: FMI = Freiburg Mindfulness Inventory; SCS = Self-Compassion Scale Path coefficients were calculated with social desirability scores as covariates.
70 Table 4-4. Self-Compassion as Mediator Between Perfectionism and Disordered Eating in Men ( n = 68) Path B SE p DISC to EAT-26 (c path) DISC to SCS SCS to EAT-26 DISC to EAT-26 (c path) .167 -.083 .005 .167 .079 -.020 .481 .089 .254 .433 .001 .254 .037 <.020 .992 .063 Note: DISC = APS Discrepancy; SCS = Self-Compassion Scale Path coefficients were calculated with social desirability scores as covariates
71 Table 4-5. Self-Compassion as Mediator Betw een Perfectionism and Disordered Eating in Women ( n = 103) Path B SE p DISC to EAT-26 (c path) DISC to SCS SCS to EAT-26 DISC to EAT-26 (c path) .126 -.090 -.726 .061 .064 -.017 -.383 .072 .194 -.467 -.216 .094 .051 <.001 .061 .397 Note: DISC = APS Discrepancy; SCS = Self-Compassion Scale Path coefficients were calculated with social desirability scores as covariates
72 Table 4-6. Internal Consistency, Means, and Standard Deviations of Study 2 Variables Measure M SD APS-R Discrepancy SCS RSES EAT-26 .97 37.13 17.89 .91 14.94 3.30 .86 32.63 10.21 .57 9.13 4.52 Note: SCS = Self-Compassion Scale (pretest score); RSES = Rosenberg Self-Esteem Scale
73 0 5 10 15 20 25 12 1 = Pretest 2 = PosttestSCS score Figure 4-1. Change in Self-Compassion for Workshop Attendees
74 CHAPTER 5 DISCUSSION The purpose of this research was to exam ine the application of Buddhist psychology constructs (particularly self-com passion) to eating disorders prev ention with college women. To accomplish this, two studies were conducted. Th e first study was correlational in nature and examined the basic relationships among relevant constructs as well as the role of selfcompassion in several mediation models involvi ng disordered eating. The second study aimed to determine the extent to which self-compassion could be increased through a one-hour outreach workshop on a university campus. Study 1 This study was designed to investigate th e relationships am ong mindfulness, selfcompassion, perfectionism, and disordered eating within a sample of university students. Selfcompassion was explored both as a mechanis m by which mindfulness may be related to disordered eating, and a mediator in the relationship between maladaptive perfectionism and disordered eating. Exploratory an alyses investigated the role of self-esteem as both a mediator and a moderator in the latter model. Preliminar y analyses indicated that gender moderated the relationships among these constructs in that relationships among these constructs were generally stronger in women than in men. Because of this and because eating disorders prevention efforts most often focus on women (Franko & Oros an-Weine, 1998, Mann et al., 1997), only women were included in major analyses. As hypothesized, self-compassion emerged as a potential mediator in the relationship between mindfulness and disordered eating. A lthough causal mechanisms (and therefore, the mediating role of self-compassion) cannot be confirmed with data collected at one time point, results indicated that self-compassion accounted for most of the variance shared by mindfulness
75 and disordered eating. Past research has nomin ated self-compassion as a potential mechanism through which mindfulness-based interventions induce change, and have shown that selfcompassion increases through participation in a mi ndfulness group (Shapiro et al., 2005; Shapiro et al., 2007). The findings of the current study are consistent with the con ceptualization of selfcompassion as a mediating mechanism, and help to extend past research to address the roles of mindfulness and self-compassion in disordered eating. Self-compassion also emerged as a partia l mediator in the relationship between maladaptive perfectionism and disordered eating. This is consistent with past research indicating that maladaptive (more than adaptive) aspects of perfectionism are associated with disordered eating concerns (Davis, 1997; Pearson & Gleaves, 2006), and that self-compassion is negatively associated with maladaptive perfec tionism (Neff, 2003a). It is im portant to note that while some of the relationship between malada ptive perfectionism and disordered eating can be attributed to self-compassion, there remains a significant direct relationship between maladaptive perfectionism and disordered eating that cannot be explained in terms of self-compassion. Contrary to expectations, th e indirect effect through se lf-compassion was not moderated by participants body image investment. Though une xpected, this finding is consistent with a study by McGee, Hewitt, Sherry, Parkin, and Flett (2005), who found that body image evaluation, but not body image investment, modera ted the relationship between perfectionistic self-presentation and eating diso rder symptoms. The authors e xplained this in terms of a diathesis-stress model, stating that ego involve ment alone (the importance of body image to a persons sense of self) may not be enough to st rengthen the relationship between perfectionism and eating disorder symptoms. Rather, perfec tionism becomes a stronger predictor of eating disorder symptoms only when a person evaluates their body image negatively. In terms of the
76 current study, it was expected th at the indirect effect of pe rfectionism through self-compassion would demonstrate a stronger relationship with disordered eating symptoms when an individual placed a high degree of importance on their a ppearance. It may be that this moderation relationship was not supported for similar reas ons: investment in ones appearance may strengthen this relationship only when body image is also evaluated negatively. Further research examining other dimensions of body image could he lp further explain this unexpected result. This study highlights the importance of self-compassion as an appropriate conceptualization of a healthy self-attitude in college women. Although negative self-attitudes have previously been examined as risk factors for the developm ent of disordered eating (Stice, 2002; Vohs et al., 1999), one unique aspect of this study is the focus on self-compassion rather than self-esteem. Because of the conceptual distinctions between self-compassion and selfesteem (Neff & Vonk, 2009), and because some re searchers have suggested that self-compassion might be a more appropriate target for interv ention (Leary et al., 2007), exploratory analyses were conducted to explore the role of self-est eem in the mediation model. When both selfcompassion and self-esteem were included as potential mediators between maladaptive perfectionism and disordered eating, only self -compassion remained a significant mediator. When self-esteem was included as a moderator in the model, it was found that the indirect effect through self-compassion was stronger when levels of self-esteem were low. This is consistent with the premise that self-compassion may serv e to buffer individuals against the potential negative effects of low self-esteem (Leary et al.). While self-esteem is the result of an evaluative process (and therefore requires a person to either change themselves or ignore inadequacies in order to have high self-esteem), self-compassion is a way of treating oneself that is characterized by kindness and nonjudgment (Neff, 2003b). Self-c ompassion may be most applicable when
77 times get tough. For instance, when failure or a perceived flaw results in a decrease in selfesteem, a nonjudgmental attitude toward self and a perception of common humanity can attenuate the possible negative outcomes. B ecause self-compassion involves an honest yet caring attitude toward self, it can motivate an individual to change in ways that are healthy rather than punitive. Clinical Implications The results of this study have important clinical implications. Although further study is required to confirm the direction of causation, this study presents mediation models that may help clinicians develop more powerful interventions to preven t or ameliorate symptoms of disordered eating. Perhaps most significantly, self-compassion emerged as a relevant construct in the prevention of disordered eating, making it a potential focu s of clinical attention. This concept could be especially useful fo r clinicians working with perfectionistic individuals. Results of this st udy suggest that levels of self-c ompassion may explain some of the link between maladaptive perfect ionism and disordered eati ng in college women. Both researchers and clinicians have su ggested that maladaptive aspects of perfectionism, such as selfcriticism, fear of evaluation, and perceived disc repancy between standards and performance, are important to address in order to reduce vulnerability to eating disorders and other problems (Ashby et al., 1998). However, addressing perf ectionism directly can be difficult when individuals perceive their perfectionism as having positive rewards. Furthermore, perfectionistic clients may have difficulty addres sing concerns that may be perc eived as failures or flaws and hence may be reluctant to seek professional help (Goldner et al., 2002). Self-compassion may provide an alternate point of intervention that is more acceptable to clients and is still related to positive outcomes. Interventions designed to increase self-compassion may be met with less resistance by perfectionistic cl ients, as they do not require cl ients to abandon the high personal
78 standards that are experienced as helpful a nd necessary. The focus on increasing a healthy attitude, rather than focusing on perceived problems, may also make such interventions less threatening. Individuals would not have to self-identify as havi ng a flaw in order to benefit from an increase in self-compassion. A focus on self-compassion could also be help ful for clinicians who take a mindfulnessbased approach. As researchers have studied the application of mindfulness to a growing array of clinical problems, clinicians are increasi ngly incorporating mindful ness into their work (Toneatto & Nguyen, 2007). However, mindfulnessbased interventions may not be appropriate for all clients. Although mindf ulness has largely been divorced from its cultural and religious context as it is infused into clinical interventions (Baer, 2003), some clients may continue to feel uncomfortable with an explicit focus on mindfulness practice beca use of cultural or religious issues (Kristeller et al., 2006). Furthermore, many clinicians have asserted that mindfulness should not be incorporated into treatment unle ss the clinician also has a personal mindfulness practice to serve as a reference point (K risteller et al., 2006; Murphy, 2006). This understandably limits the practical application of mindfulness-ba sed interventions. As selfcompassion explained the majority of the re lationship between mindf ulness and disordered eating in the present study, it is possible that a focus on se lf-compassion, separate from mindfulness practice, could have similar therapeu tic value. This could be especially helpful when viewing clinical problems through a preventa tive lens. Though it is likely that the practice of mindfulness increases resilience and decrease s individuals vulnerability to mental health problems (Brown & Ryan, 2003), the cultivation of mindfulness is a long term endeavor. Selfcompassion may be more easily changed than mindf ulness, and thus may present fewer practical obstacles. Before putting this principle into cl inical practice, however, further research should
79 first confirm the direction of causality proposed in this study and investigate whether a focus on self-compassion alone is indeed as helpful as a mindfulnessbased intervention. Results of this study also serve to draw c linicians attention to the distinction between self-compassion and self-esteem. A great deal of clinical atten tion goes into improving individuals self-attit udes, and self-esteem is an importa nt component of several universal prevention programs (Neff, 2008). However, effort s to increase self-esteem can be problematic. Because self-esteem is inherently evaluative, it is difficult to increase an individuals self-esteem without changing other aspects of the person. The potential pitfalls of self-esteem are evident in conceptualizations of some c linical problems, in which indi viduals engage in maladaptive behaviors as a means of main taining self-esteem (Crocker & Park, 2004). Alternatively, individuals may maintain globa lly high self-esteem by overlooki ng legitimate weaknesses, as evidenced by the association between high self-e steem and narcissism (Baumeister et al., 1996; Neff, 2008). Self-compassion appears to have many of the same benefits of self-esteem, a trend that was borne out in the present research. B ecause it is free from an evaluative component, it can be modified independently. This may be helpfu l for clinicians who seek to modify clients self-attitudes, as well those developing outreac h and prevention efforts aimed at fostering resilience. Limitations and Future Directions There are several limitations to the present study that should inform the interpretation of results. Perhaps most importantly, data for th is study were collected at one time point. The models examined here are based on a presumption of temporal sequen cing that is based on previous literature. For example, perfectio nism has been found to precede the onset of disordered eating symptoms (Fairburn et al., 199 9), and changes in mindfulness have been found to predict changes in self-compa ssion (Shapiro et al., 2005). Howe ver, there is no way to rule
80 out alternative explanations for the relationships found in these data. For instance, a struggle with disordered eating could lead an individual to be more se lf-critical or reduce their selfesteem. Though the results of this study suggest potential causal mechanisms explaining disordered eating, further research using data collected at multiple time points (and, ideally, experimental manipulation) would be needed to confirm the direction of causality. When interpreting the relationships among constr ucts in this study, it is also important to consider that all data were collected through se lf-report. This method was chosen because, for many of the variables of interest (especially th ose related to self-attitudes) there is no other reliable method of assessment. Some limitations of self-report, such as the tendency to respond in a socially desirable manner, were minimized through study design and statistical analysis. However, the measured variables in this study also share method variance which cannot be parceled out without multiple forms of measur ement. While this is common and sometimes unavoidable in psychological resear ch, results of this study should be interpreted in light of this limitation. It may be especially important to consid er the operationalization of the (presumed) outcome variable when interpreting this study. Although the dependent vari able consists of a largely behavioral outcome, it is measured enti rely by self-report. The EAT-26 has been judged to be a valid indicator of disordered eating concerns. However, inclusion of other data (interview data, diagnostic check lists, behavioral reports) may have strengthened the claims made in this study. The psychometric properties of the EAT-26 may also be cause for concern. The low internal consistency of th is measure is not surprising in this sample given the process of scale construction. The EAT-26 was designed to measure thr ee separate dimensions of disordered eating, though popular use has trended toward the use of a total score. Furthermore,
81 the EAT-26 was designed to detect cases of anorexia nervosa or relate d disorders, and has evidenced higher reliability in c linical samples (Garner et al., 1982). Nevertheless, it is possible that low internal consistency ar tificially suppressed relationships between predictors and the outcome variable. Higher relia bility may have been achieved through use of a sample with higher incidence of disordered eat ing attitudes. Future research may also improve on this design by including multiple measures of the outcome variable. There are several important c onsiderations regarding sample characteristics that should inform inferences about the ge neralizability of this study. In this study, participants were undergraduate college students who approximated the race/ethnicity make up of the university they attended. In many ways, recruiting from this population is potentially useful in that college students are typically the recipi ents of eating disorder prevention efforts. However, it is unknown if the results obtained in this study would apply to non-student populations (such as adolescents or clinical populat ions). Participants for this study were recruited from undergraduate classes, and were not necessarily experiencing pr oblems with perfectionism or disordered eating. It is reasonable to assume that these students would be different from individuals who would normally be recipients of interventions to reduce disordered eating. Replication of this study in clinical samples c ould inform whether and how these results could be applied in treatment. Several findings emerged through this study that warrant furthe r investigation. For instance, the initial mediation model in which self-compassion mediated the relationship between maladaptive perfectionism and disordered ea ting was supported in women but not in men. Because of the relatively small numbers of men in this sample (n = 68), this finding was not explored further. However, given the recent in creased attention to eati ng disorders in college
82 men (Petrie & Rogers, 2001), this presents a promising avenue for future research. It is possible that the pathways to disordered eating are different for men and wo men, which could have important implications for intervention. Further research using larger groups of college men would be needed to confirm or further explain this finding. Similarly, even with significant regression coefficients, there was a large proport ion of variance (close to 90%) in disordered eating that was not accounted for by the models presen ted here. This is not surprising, given that disordered eating is known to be a complex phenomenon with multiple determinants (Tylka & Subich, 2004). Several models of eating disorder development em phasize predictors that were not measured in this study, in cluding sociocu ltural and relational variables. Many of these variables, such as internalization of thin ideal, have been identified as appropriate targets for intervention. It is unknown whether self-com passion would explain additional variance in disordered eating when other known risk factors are accounted for. Conceptual definitions of self-compassion would presume that it would remain relevant, possi bly acting as a moderator to buffer the effects of other risk factors. Futu re research could examine the role of selfcompassion within a more complete multidimensional model of disordered eating to determine if this is the case. Study 2 Results of Study 1 indicated that self-com pa ssion may be an important mechanism in the relationship between maladaptive perfectionism and disordered eating, particularly in college women. Study 2 aimed to build on this result by examining whether self-compassion could be increased through a one hour self-compassion work shop developed for college women. In order to identify women who may be vulnerable to developing eating disorders, the workshop was targeted toward students who identified as struggling with self-critici sm and negative attitudes toward themselves, as these characteristics have been suggested as psychological risk factors for
83 the development of disordered eating (Vohs et al., 1999). Additionally, the workshop was advertised through agencies thought to interact with women w ho may be at increased risk (Panhellenic Council, Campus H ealth Services, Wellness and H ealth Promotion, Counseling and Consultation). Eight women (both undergraduate and graduate students) attended these workshops and completed preand posttest questionnaires. Two of these women indicated past concerns with eating, weight, or body image, but none of them currently scored above the cutoff of on the EAT-26. This supports the notion that wo rkshop participants were either free from disordered eating concerns, or evidenced subclinical levels of such concerns. This distinction is important, as this workshop was characterized as prevention. These womens scores on the disordered eating measure were consistent w ith this characterizati on. Consistent with expectations, these women scored higher on the self-compassion scale after the workshop than before the workshop. This change was large in magnitude, which was fairly surprising given the brief nature of the interv ention. This result is consistent with the idea that self-compassion is an appropriate target for intervention and perhaps more easily modified th an other self-attitudes (Neff, 2008). Importantly, inspection of prea nd posttest scores for i ndividual participants indicated that scores either remained fairly st able or increased over time. There was no evidence that the workshop had a detrimental effect on any of the participants. Implications Results of this study offer initial support for the integration of self-compassion into preventative outreach efforts with college women. Consistent with past intervention research, results indicated that self-compassion could be modified with direct instruction and practice (Adams & Leary, 2007; Gilbert & Procter, 2006; Shapiro et al ., 2005). However, this study extends past research by utilizing a workshop format commonly used in university counseling
84 center work (Boyd et al., 2003; Gu inee & Ness, 2000). This increas es the external validity of research findings, and reflects an intervention strategy that could be easily replicated. University counseling centers are increasingl y focusing on outreach programming as an efficient way to reach out to students, particularly those st udents who would not otherwise pursue formal counseling (Marks & Laughlin, 2005). In the context of eating disorders prevention, this strategy would enable clinicians to reach a larger number of students than can be reached through individual therapy, while still focusing re sources on students with elevated risk. A focus on self-compassion may help overcom e some common problems that emerge in eating disorders prevention. For instance, one complicating factor in designing effective outreach is that the audience is often com posed of both women who are symptom-free and women who have subclinical eating or weight concerns (Mann et al ., 1997). Statistics indicate that a portion of the latter group may also be in the early stages of developing a full syndrome eating disorder (Striegel-Moore et al., 1989). Prevention programs that focus on giving information about eating disorders, or featuring testimonies of rec overed individuals, may alternatively be stigmatizing or triggering for wo men who are already expe riencing some level of concern (Carter, 1997). However, targeting prevention efforts to ward higher risk populations (who are likely already experiencing some leve l of concern) can also be problematic, as individuals may be reluctant to self-identify as having thes e concerns. A focus on selfcompassion bypasses some of these difficulties by addressing an issue that may elevate a persons eating disorders risk, but one with which women will be more willing to self-identify. Furthermore, because the focus of the workshop content is unrelated to eating or body image, this strategy does not run the risk of influencing participants attitudes in a way that increases maladaptive behavior or decrease s the likelihood of help-seeking.
85 The focus of this workshop on a self-attitude rather than on eating or weight concern also lends itself to outreach efforts beyond eating disorders prevention. As self-compassion is thought to be related both to health-promoting behaviors and resilience in the face of difficulty (Neff et al., 2005), training in self-compassion fi ts well with the emphasis on wellness promotion found in many universities (Hermon & Davis, 2004). Consistent with the nonspecific vulnerability-stressor model (NSVS; Levi ne & Smolak, 2001), decreasing psychological vulnerability may result in decrea sed risk for numerous behavioral health problems. As such, a focus on self-compassion could have important impli cations for other campus initiatives such as suicide prevention or drug abuse prevention. Limitations and Future Directions Though this study offers preliminary support for the inclusion of self-compassion in preventative outreach interventions with college women, there are several limitations to consider. The sample, though reasonably diverse, was quite sm all and may differ in important ways from the larger population of univers ity women. Concerns about this are somewhat reduced by the similarities between this sample and the Study 1 sample. However, the small sample undoubtedly reduced variability in measures a nd may not have captured the full range of characteristics likely to be found in a larger sample. For instance, participants represented just a few racial/ethnic groups and in cluded fewer young (age 18 and 19) undergraduate students. As these students are often major target populations for outreach interventi ons (Brinson & Kottler, 1995), future research may intentionally seek to increase representation from these groups. Interestingly, EAT-26 scores for this group were all below the clinical cutoff indicative of disordered eating. This was interpreted as a strength, as preventative programming would ideally focus on individuals who have not yet de veloped a given disorder. However, given the prevalence of disordered eating among college wo men, it is likely that a larger sample would
86 have included a broader range of disordered eatin g scores, including some representing clinical levels of distress. It would be interesting to learn whether this workshop was more or less helpful (or harmful) for women already e xperiencing disordered eating symptoms. In all research designs, there is a tradeoff be tween internal and external validity. In this study, the aim was to incorporate self-compassion in to an outreach activity that could be easily replicated in college counseling centers. C hoices involving study design were made favoring external validity. It was im portant that the participants be real workshop attendees participating in a real outreach activity. However, this limited the amount of control that could be exercised over study conditions. This tradeoff is evident in the single group pre-post design, which somewhat limits the conclusions that can be drawn from this study. Because there was no control group, it is possible that participants would have increased in self-compassion even without an intervention and it is impossible to conclusively rule out alternative explanations for this change, such as regression toward the mean. Though it seems unlikely that regression toward the mean would account for all of the change observed in these participants, as scores increased even for individuals whose pretest scores were higher than average, future research involving a control group would incr ease confidence in these results. The collection of data at only two time points also means there is limited in formation about the trend over time. Data was not collected at follow up in this study because of institutional concerns about privacy and desire not to increase the burden on counseling center clie nts. However, future research using data collected at three or more time points could help determine whether these gains are maintained over time. It is also important to recognize that this study did not actually measure changes in disordered eating following the workshop. The d ecision of which measures to include at each
87 time point was influenced largely by the limited time available for both content presentation and survey administration (limited to one hour total) and by a desire not to overly burden workshop participants. This decision was also influenced by considering which variables would be likely to show immediate change. As self-compassion was hypothesized as a mediating mechanism and was the focus of workshop content, it made most sense to measure changes in this variable. Disordered eating, on the other ha nd, is thought to develop over time as a result of numerous factors. Certain behavioral questions on the EAT26 even specify a reference period of the past six months. It therefore seems illogical to assu me that responses to th ese items would change immediately following a one hour intervention. Nevertheless, the characterization of this workshop as eating disorders prevention is specul ative at this point. Future research should include a measure of disordered eating at follow up in order to determine whether changes in self-compassion actually translate into changes in disordered eating. Conclusion The two studies described in this research ma ke an important contri bution to the literature on the prevention of disordered eating in college women. Alt hough perfectionism has long been known to relate to disordered eating, identifyi ng ways of addressing maladaptive perfectionism in clinical work has been a continued challenge Results of this study identified self-compassion as an important mechanism linking maladaptiv e perfectionism and disordered eating and a potential target for intervention. Intervening at the level of self-compassion may have several important benefits over attempts to directly modify perfectionism and increased levels of selfcompassion may relate to lower levels of disorder ed eating. This may be particularly true in women with low self-esteem. Furthermore, prel iminary results indicate that self-compassion can be addressed effectively thr ough an outreach workshop. This highlights self-compassion as a promising focus for future preventative outreach efforts with college women.
88 APPENDIX A STUDY 1 INFORMED CONSENT Purpose of the resea rch study: The purpose of this study is to examine the experiences, attit udes, and behaviors of college students and how these relate to psychological health. What you will be asked to do in the study: If you agree to participat e in the study, you will be asked to co mplete a series of questionnaires related to your attitudes, feelings, and behavi or. These questionnaires will be administered online and will take approximately 30-45 minutes to complete. Time required: 45 minutes Risks and Benefits: If you agree to partic ipate in this research, you may e xperience some minor emotional discomfort in responding to some of the questionn aire items. If your par ticipation in this study raises concerns that you would lik e to discuss further, please cont act the University of Florida Counseling Center at (352) 3921575 or Student Mental Health Services at (352) 392-1171. It is unlikely that you will benefit directly as a result of your partic ipation in this study. However, the results of this study will be used to better understand colle ge students attitudes and behaviors and to develop more effective ways of contributing to college students psychological health. Compensation: You will not be compensated for participation in this study. Confidentiality: Your participation in this resear ch is confidential. Only the principal investigator will have access to your identity and w ill not maintain any link between you and your responses. If any portion of this resear ch is published, no personally id entifying information will be disclosed. To make sure your participation is confidential, only a code number will be included on your survey responses. Your survey results will not influence your academic standing or any university services available to you. Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not participating. Your choice of whether or not to participat e will in no way affect your academic standing. Right to withdraw from the study: You have the right to withdraw from the study at anytime without cons equence. Additionally, you have the right to choose not to an swer any of the survey questions. Whom to contact if you have questions about the study: Jennifer Stuart, Graduate Student, Department of Psychology, PO Box 112250, University of Florida, Gainesville, FL 32611; phone (727) 204-9070
89 Kenneth G. Rice, PhD, Department of Ps ychology, PO Box 112250, University of Florida, Gainesville, FL 32611; phone (352) 273-2119. Whom to contact about your rights as a research participant in the study: IRB02 Office, Box 112250, University of Florida, Gainesville, FL 32611-2250; phone 392-0433. Agreement: I have read the procedure described above. I volunt arily agree to pa rticipate in the procedure and I have received a copy of this description. Participant: ___________________________________________ Date: _________________ Principal Investigat or: ___________________________________ Date: _________________
90 APPENDIX B STUDY 1 DEMOGRAPHIC QUESTIONNAIRE Please provide som e basic information about yourself by responding to the following items: 1. Please indicate your et hnic/racial background. ___ African American/Black ___ Asian American/Pacific Islander ___ Caucasian/White ___ Hispanic/Latino/a ___ Native American ___ Biracial/Multiracial ___ International Student ___ Other Please describe: _____________________ 2. Please indicate your gender. ___ Male ___ Female ___ Transgender 3. Please indicate your sexual orientation. ___ Lesbian ___ Gay ___ Bisexual ___ Heterosexual ___ Unsure ___ Other Please describe: ____________________ 4. Please choose the phrase that best describes your academic standing. ___ First year undergraduate (college freshman) ___ Second year undergraduate ___ Third year undergraduate ___ Fourth year or beyond undergraduate ___ Graduate/professional student 5. What is your major or intended major? ____________________________ 6. Please indicate your age. ____ 7. What is your current he ight? ____ feet. ____ inches 8. What is your current weight, in pounds? ____ pounds 9. What was your highest adult weig ht, excluding pregnancy? ____ pounds
91 10. What would be your ideal weight? ____ pounds 11. Compared to other people your age, how would you rate your level of physical health? ___ Very unhealthy (less healthy than most of your peers) ___ Somewhat unhealthy ___ Average ___ Fairly healthy ___ Very healthy (one of th e healthiest people you know) 12. When was your last visit to a healthcare provider? Month: _______ Year: _______ 13. Are you a member of an intercollegiate athletic team? ___ yes ___ no 14. Are you a member of a campus Greek organization? ___ yes ___ no 15. Have you ever sought or received treatment fo r concerns related to eating, weight, or body image? ___ yes ___ no 16. If you responded yes to question #13, are y ou currently receiving treatment for these concerns? ___ yes ___ no 17. What are some characteristics people might use to describe you if they knew you well? ____________________ ___________________ _____________________ 18. What are some things you feel you do really well? _____________________ ___________________ _____________________
92 APPENDIX C EATING ATTITUDES TEST 26 Please choose one response by checking one res ponse to the right for each of the following statements: ALWAYS USUALLY OFTEN SOMETIMES RARELY NEVER 1. Am terrified about being overweight. ____ ____ ____ ____ ____ ____ 2. Avoid eating when Im hungry ____ ____ ____ ____ ____ ____ 3. Find myself preoccupied with food ____ ____ ____ ____ ____ ____ 4. Have gone on eating binges where I feel that I may not be able to stop ____ ____ ____ ____ ____ ____ 5. Cut my food into small pieces ____ ____ ____ ____ ____ ____ 6. Aware of the calori e content of the foods that I eat ____ ____ ____ ____ ____ ____ 7. Particularly avoid food with high carbohydrate content (i.e. bread, rice, potatoes, etc.) ____ ____ ____ ____ ____ ____ 8. Feel that others w ould prefer if I ate more ____ ____ ____ ____ ____ ____ 9. Vomit after I have eaten ____ ____ ____ ____ ____ ____ 10. Feel extremely guilty after eating ____ ____ ____ ____ ____ ____ 11. Am preoccupied with a desire to be thinner ____ ____ ____ ____ ____ ____ 12. Think about burning up calories when I exercise ____ ____ ____ ____ ____ ____ 13. Other people think that I am too thin ____ ____ ____ ____ ____ ____ 14. Am preoccupied with the thought of having fat on my body ____ ____ ____ ____ ____ ____ 15. Take longer than others to eat my meals ____ ____ ____ ____ ____ ____ 16. Avoid foods with sugar in them ____ ____ ____ ____ ____ ____ 17. Eat diet foods ____ ____ ____ ____ ____ ____
93 18. Feel that food controls my life ____ ____ ____ ____ ____ ____ 19. Display self-control around food ____ ____ ____ ____ ____ ____ 20. Feel that others pressure me to eat ____ ____ ____ ____ ____ ____ 21. Give too much time and thought to food ____ ____ ____ ____ ____ ____ 22. Feel uncomfortable after eating sweets ____ ____ ____ ____ ____ ____ 23. Engage in dieting behavior ____ ____ ____ ____ ____ ____ 24. Like my stomach to be empty ____ ____ ____ ____ ____ ____ 25. Have the impulse to vomit after meals ____ ____ ____ ____ ____ ____ 26. Enjoy trying rich new foods ____ ____ ____ ____ ____ ____ In the past six months have you: YES NO A. Gone on eating bines here you feel you may not be able to stop? ____ ____ (Eating much more than most people would eat under the same circumstances) If you answered yes, how often during the worst week? ________ B. Ever made yourself sick (vomited) to control your weight or shape? ____ ____ If you answered yes, how often during the worst week? ________ C. Ever used laxatives, diet pills or diuretics (water pill s) to control your weight or shape? ____ ____ If you answered yes, how often during the worst week? ________ D. Ever been treated for an eating disorder? ____ ____ If yes, when? ___________
94 APPENDIX D ALMOST PERFECT SCALE-REVISED The following items are designed to measure certa in attitudes people have toward themselves, their performance, and toward others. It is impor tant that your answers be true and accurate for you. In the space next to the statement, please en ter a number from 1 (strongly disagree) to 7 (strongly agree) to describe your degree of agreement with each item. STRONGLY DISAGREE SLIGHTLY NEUTRAL SLIGHTLY AGREE STRONGLY DISAGREE DISAGREE AGREE AGREE 1 2 3 4 5 6 7 _____ 1. I have high standards for my performance at work or at school. _____ 2. I am an orderly person. _____ 3. I often feel frustrated because I cant meet my goals. _____ 4. Neatness is important to me. _____ 5. If you dont expect much out of yourself you will never succeed. _____ 6. My best just never seems to be good enough for me. _____ 7. I think things should be put away in their place. _____ 8. I have high expectations for myself. _____ 9. I rarely live up to my high standards. _____ 10. I like to always be organized and disciplined. _____ 11. Doing my best never seems to be enough. _____ 12. I set very high standards for myself. _____ 13. I am never satisfied with my accomplishments. _____ 14. I expect the best from myself. _____ 15. I often worry about not measuring up to my own expectations. _____ 16. My performance rarely measures up to my standards. _____ 17. I am not satisfied even when I know I have done my best. _____ 18. I am seldom able to meet my own high standards for performance. _____ 19. I try to do my best at everything I do. _____ 20. I am hardly ever satisfied with my performance. _____ 21. I hardly ever feel that what Ive done is good enough. _____ 22. I have a strong need to strive for excellence. _____ 23. I often feel disappointment after completing a task because I know I could have done better. _____ 24. Using the scale above, please rate the degree to which you agree that you are perfectionistic.
95 APPENDIX E SELF-COMPASSION SCALE HOW I TYPICAL LY ACT TOWARDS MYSELF IN DIFFICULT TIMES Please read each statement carefully before answ ering. To the left of each item, indicate how often you behave in the stated manner, using the following scale: Almost Almo st never al ways 1 2 3 4 5 _____ 1. Im disapproving and judgmental about my own flaws and inadequacies. _____ 2. When Im feeling down I tend to obses s and fixate on everything thats wrong. _____ 3. When things are going badly for me, I see the difficulties as part of life that everyone goes through. _____ 4. When I think about my inadequacies, it te nds to make me feel more separate and cut off from the rest of the world. _____ 5. I try to be loving towards myse lf when Im feeling emotional pain. _____ 6. When I fail at something important to me I become consumed by feelings of inadequacy. _____ 7. When I'm down and out, I remind myself that there are lots of other people in the world feeling like I am. _____ 8. When times are really difficu lt, I tend to be tough on myself. _____ 9. When something upsets me I try to keep my emotions in balance. _____ 10. When I feel inadequate in some way, I try to remind myself that feelings of inadequacy are shared by most people. _____ 11. Im intolerant and impatient towards t hose aspects of my personality I don't like.
96 _____ 12. When Im going through a very hard time, I give myself the caring and tenderness I need. _____ 13. When Im feeling down, I tend to feel lik e most other people ar e probably happier than I am. _____ 14. When something painful happens I try to take a balanced view of the situation. _____ 15. I try to see my failings as part of the human condition. _____ 16. When I see aspects of myself th at I dont like, I get down on myself. _____ 17. When I fail at something important to me I try to keep things in perspective. _____ 18. When Im really struggling, I tend to feel like other people must be having an easier time of it. _____ 19. Im kind to myself when Im experiencing suffering. _____ 20. When something upsets me I get carried away with my feelings. _____ 21. I can be a bit cold-hearted toward s myself when I'm experiencing suffering. _____ 22. When I'm feeling down I try to approach my feelings with curiosity and openness. _____ 23. Im tolerant of my own flaws and inadequacies. _____ 24. When something painful happens I tend to blow the incident out of proportion. _____ 25. When I fail at something that's important to me, I tend to feel alone in my failure. _____ 26. I try to be understanding and patient towa rds those aspects of my personality I don't like.
97 APPENDIX F FREIBURG MINDFULNESS INVENTORY Rarely Occasionally Fairly Often Almost Always 1 2 3 4 1. ____ I am open to the experience of the present moment. 2. ____ I sense my body, whether ea ting, cooking, cleanin g or talking. 3. ____ When I notice an absence of mind, I gently return to the experien ce of the here and now. 4. ____ I am able to appreciate myself. 5. ____ I pay attention to whats behind my actions. 6. ____ I see my mistakes and difficulties without judging them. 7. ____ I feel connected to my experience in the here-and-now. 8. ____ I accept unpleasant experiences. 9. ____ I am friendly to myself when things go wrong. 10. ____ I watch my feelings without getting lost in them. 11. ____ In difficult situations, I can pause without immediately reacting. 12. ____ I experience moments of i nner peace and ease, even when things get hectic and stressful. 13. ____ I am impatient with myself and with others. 14. ____ I am able to smile when I notice how I sometimes make life difficult.
98 APPENDIX G APPEARANCE SCHEMAS INVENTORY REVISED The statements below are beliefs that people may or may not have about their physical appearance and its influence on life. Deci de on the extent to which you personally disagree or agree with each statement and enter a num ber from 1 to 5 in the space on the left. There are no right or wrong answer s. Just be truthful about your personal beliefs. 1 2 3 4 5 Strongly Mostly Neit her Agree Mostly Agree Strongly Disagree Disagree nor Disagree Agree _____ 1. I spend little time on my physical appearance. _____ 2. When I see good-looking people, I wonde r about how my own looks measure up. _____ 3. I try to be as physica lly attractive as I can be. _____ 4. I have never paid much attention to what I look like. _____ 5. I seldom compare my appearance to that of other people I see. _____ 6. I often check my appearance in a mi rror just to make sure I look okay. _____ 7. When something makes me feel good or bad about my looks, I tend to dwell on it. _____ 8. If I like how I look on a given day, its easy to feel happy about other things. _____ 9. If somebody had a negative reaction to what I look like, it wouldnt bother me. _____ 10. When it comes to my physical appearance, I have high standards. _____ 11. My physical appearance has had little influence on my life. _____ 12. Dressing well is not a priority for me. _____ 13. When I meet people for the first time, I wonder what they think about how I look. _____ 14. In my everyday life, lots of things happen that make me think about wh at I look like. _____ 15. If I dislike how I look on a given day, it s hard to feel happy about other things. _____ 16. I fantasize about what it would be like to be better looking than I am. _____ 17. Before going out, I make sure th at I look as good as I possibly can. _____ 18. What I look like is an im portant part of who I am. _____ 19. By controlling my appearance, I can control many of the social and emotional events in my life. _____ 20. My appearance is responsible for much of whats happened to me in my life.
99 APPENDIX H ROSENBERG SELF-ESTEEM SCALE Circle the appropriate number for each statem ent depending on whether you strongly agree, agree, disagree, or str ongly disagree with it. Strongly Agree Disagree Strongly Agree Disagree 1. On the whole, I am satisfied with myself. 1 2 3 4 2. At times I think I am no good at all. 1 2 3 4 3. I feel that I have a number of goo d qualities. 1 2 3 4 4. I am able to do things as well as most other people. 1 2 3 4 5. I feel I do not have much to be proud of. 1 2 3 4 6. I certainly feel useless at times. 1 2 3 4 7. I feel that Im a pers on of worth, at least on an equal plane with others. 1 2 3 4 8. I wish I could have more respect for myself. 1 2 3 4 9. All in all, I am inclined to feel that I am a failure. 1 2 3 4 10. I take a positive attitude toward my self. 1 2 3 4
100 APPENDIX I MARLOWE-CROWNE SOCIAL DESIRABILITY SCALE Listed below are a number of statements concerni ng personal attitudes and traits. Read each item and decide whether the statement is true or false as it pertains to you personally. Circle T if this item is true as it pertains to you or F if it is false as it pertains to you. 1. It is sometimes hard for me to go on with my work if I am not encouraged. T F 2. I sometimes feel resentful when I dont get my way. T F 3. On a few occasions, I have given up doing something because I thought too little of my ability. T F 4. There have been times when I felt like rebelling against people in authority even though I knew they were right. T F 5. No matter who Im talking to, Im always a good listener. T F 6. There have been occasions when I took advantage of someone. T F 7. Im always willing to admit it when I make a mistake. T F 8. I sometimes try to get even rath er than forgive and forget. T F 9. I am always courteous, even to people who are disagreeable. T F 10. I have never been irked when peopl e expressed ideas very different from my own. T F 11. There have been times when I was quite jealous of the good fortune of others. T F 12. I am sometimes irritated by people who ask favors of me. T F 13. I have never deliberately said some thing that hurt someones feelings. T F
101 APPENDIX J STUDY 2 INFORMED CONSENT Purpose of the resea rch study: The purpose of this study is to learn more about students attitude s toward themselves. What you will be asked to do in the study: If you agree to participat e in the study, you will be asked to complete two questionnaires related to your attitudes, feelings, and behavior. One series will be provided now. A second questionnaire will be available at the end of the workshop. Time required: 10 minutes for each set of questionnaires 20 minutes total Risks and Benefits: If you agree to partic ipate in this research, you may e xperience some minor emotional discomfort in responding to some of the questionn aire items. If your par ticipation in this study raises concerns that you would like to disc uss further, please contact Counseling and Consultation at (480) 965-6146. It is unlikely that you will benefit directly as a result of your partic ipation in this study. However, the results of this study will be used to better understand colle ge students attitudes and behaviors and to develop more effective ways of contributing to college students psychological health. Compensation: You will not be compensated for participation in this study. Confidentiality: Your participation in this resear ch is confidential. Only the principal investigator will have access to your identity and w ill not maintain any link between you and your responses. If any portion of this resear ch is published, no personally id entifying information will be disclosed. To make sure your participation is confidential, only a code number will be included on your survey responses. Your survey results will not influence your academic standing or any university services available to you. To protect your privac y, your survey answers will be examined separately from any identifying information, and none of your survey responses will be entered until after the completion of the workshop. Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not participating. Your choice of whether or not to participate will in no way affect your academic standing or your eligibility for services fr om Counseling and Consultation. Though the study is designed to evaluate the effects of a workshop, your decision whether to participate in the study will not affect your eligibility to participate in the workshop
102 Right to withdraw from the study: You have the right to withdraw from the study at anytime without cons equence. Additionally, you have the right to choose not to answer any of the survey questions. Whom to contact if you have questions about the study: Jennifer Stuart, Psychology Intern, Counseli ng and Consultation, PO Box 871012, Arizona State University, Tempe, AZ 85287; phone (727) 204-9070 Kenneth G. Rice, PhD, Department of Ps ychology, PO Box 112250, University of Florida, Gainesville, FL 32611; phone (352) 273-2119. Whom to contact about your rights as a research participant in the study: IRB02 Office, Box 112250, University of Fl orida, Gainesville, FL 32611-2250; phone 392-0433. Agreement: I have read the procedure described above. I volunt arily agree to pa rticipate in the procedure and I have received a copy of this description. Participant: ___________________________________________ Date: _________________ Principal Investigat or: ___________________________________ Date: _________________
103 APPENDIX K STUDY 2 DEMOGRAPHIC QUESTIONNAIRE We would like to know more about the students who are participating in this study. P lease provide some basic information about your self by responding to the following items: 1. Please indicate your et hnic/racial background. ___ African American/Black ___ Asian American/Pacific Islander ___ Caucasian/White ___ Hispanic/Latino/a ___ Native American ___ Biracial/Multiracial ___ Other Please describe: _____________________ 2. Are you an international student? _______ 3. Please indicate your gender. ___ Male ___ Female ___ Transgender 4. Please indicate your sexual orientation. ___ Lesbian ___ Gay ___ Bisexual ___ Heterosexual ___ Unsure ___ Other Please describe: ____________________ 5. Please choose the phrase that best describes your academic standing. ___ First year undergraduate (college freshman) ___ Second year undergraduate ___ Third year undergraduate ___ Fourth year or beyond undergraduate ___ Graduate/professional student 6. What is your major or intended major? ____________________________ 7. Please indicate your age. ____ 8. Compared to other people your age, how would you rate your level of physical health? ___ Very unhealthy (less healthy than most of your peers) ___ Somewhat unhealthy
104 ___ Average ___ Fairly healthy ___ Very healthy (one of th e healthiest people you know) 9. When was your last visit to a healthcare provider? Month: _______ Year: _______ 10. Are you a member of the honors college? ___ yes ____ no 11. Are you a member of an intercollegiate athletic team? ___ yes ___ no 12. Are you a member of a club sports team? ___ yes ___ no 13. Are you a member of a campus Greek organization? ___ yes ___ no 14. Have you ever sought or received treatment fo r concerns related to eating, weight, or body image? ___ yes ___ no 15. If you responded yes to question #14, are y ou currently receiving treatment for these concerns? ___ yes ___ no 16. What are some characteristics people might use to describe you if they knew you well? ____________________ ___________________ _____________________ 16. What are some things you feel you do really well? _____________________ ___________________ _____________________
105 APPENDIX L SELF-COMPASSION WORKSHOP RECRUITMENT FLIER A Self-Compassion Workshop presented by Arizona State University Counseling and Consultation Self-compassion has been linked with happin ess, well-being, and an increased ability to cope with stress. Yet most of us are hard er on ourselves than we are on others! In this workshop, participants will explore so me ways self-criticism keeps them from being as healthy and happy as they would like to be. Participants will learn valuable tools for fostering self-compassion in thei r everyday lives and quieting that selfcritical voice. This workshop is design ed to help you build a healthier and more compassionate relationship with yourself. For more information, please contact: Counseling and Consulta tion (480) 965-6146
106 APPENDIX M SELF-COMPASSION WRITING EXERCISE INSTRUCT IONS Exercise 1: Identifying Your Inner Critic Take a few minutes to write about an issu e you have that tends to make you feel inadequate or bad about yourself. Try to focus on just one issue. What is it about yourself that you often criticize? How does this aspect of yourself make you feel (scared, sad, insecure, angry)? What are some things you say to yourself? Be honest. No one is going to read this but you. Exercise 2: Replacing Your Inner Critic Revisit the issue you wrote about in Exercise 1. Write a paragraph to yourself about this issue, this time from the perspective of a perfectly compassionate, caring friend. What would this friend say about your flaw? How would your friend convey thei r caring and compassion to you? How would they help you put this in perspective? Would they suggest any possible cha nges? How would they phrase this?
107 APPENDIX N SELF COMPASSION MEDI TATION INSTRUCTIONS 1. Find a co mfortable seated position. Close your ey es. Allow your body to be held by the chair. Notice the bodily sensation of contact with the chair. 2. Relax your abdomen. Notice that your breath is already moving on its own. Follow the breath for a few moments. If other thoughts enter your mind (which they will), just let them pass through. 3. Bring to mind a visual image or a felt se nse of someone who embodies the quality of lovingkindness. This can be anyone whom you ha ve unconditional empathy and love for a best friend, a child, or a pet often works well. Imagine that this pe rson is sitting across from you. 4. Now imagine that you are emanating feelings of gratitude and love toward this person. Imagine the emotional connection that exists between you. Maybe try emanating the following wishes on their behalf*: May you be safe and free from danger. May you be healthy and fr ee from physical suffering. May you be happy and free from mental suffering. May you live a life of peace and contentment. 5. When your attention wanders, s imply return to this image or felt sense of the person and begin again. *This exercise can be repeated as needed, having participants substitute an image of themselves. Notes and Special Instructions: When you first begin meditating, generating a feeli ng of compassion may be difficult. This is why we start with someone you naturally have warm, empathic feelings for. Focusing your breath on your chest, abdomen, and the area aro und your heart can sometimes help you tune in to your emotions. Once you have practiced this technique using the im age of a warm, positive relationship, try also substituting the image of other people those you have no strong feelings for. Eventually substitute the image of yourself, and pr actice cultivating empathy and acceptance for your own experience. With repeated practice, it becomes easier to generate these feelings during difficult times. Adapted from: Morgan, W.D., & Morgan, S. T. (2005). Cultivating attention an d empathy. In C. K. Germer R. D. Siegel, and P. R. Fulton (Eds.). Mindfulness and Psychotherapy Guilford Press.
108 APPENDIX O LIST OF DEFINITIONS AND TERMS DISORDERED EATING: This term refers to a range of problematic attitudes and behaviors related to food and weight. These attitudes and behaviors exist along a continuum ranging from preoccupation with food, body im age, or dieting to full syndrome Anorexia Nervosa, Bulimia Nervosa, or Eating Disorder NOS. For the purpose of this study, disordered eating will be operationalized as elevations on the Eating Attitudes Test (EAT-26; Garner and Garfinkel, 1979). Due to the diagnostic terminology used in much of the existing literature, the terms eating disorders and disordered eating will be used interchangeably th roughout the literature review and discussion. SELF-COMPASSION: This term refers to a way of relating to oneself and ones experience that is characterized by openness and acceptance, as well as a desire to alleviat e suffering through self-kindness. For the purpose of this study, self-compassion will be operationalized as scores on the Self-Compassion Scale (SCS; Neff, 2003). MINDFULNESS: This term refers to a persons ability to attend to the present moment in a nonjudgmental fashion. Mindfulness, as measured in this study, is thought to consist of interrelated cognitive, process, and attitudinal components. For the purpose of this study, mindfulness will be measured by scores on the Freiburg Mindfulness Inventory (FMI; Buchheld, Grossman, & Walach, 2001). MALADAPTIVE PERFECTIONISM: This term refers to compone nts of perfectionism, including harsh self-criticism and perceived discrepancy between standards and performance, th at are typically related to problematic outcomes. For the purpose of this study, maladaptive perfectionism will be operationalized as elevations on the Discrepancy scale of the Almost Perfect Scale-Revised (APS-R; Slaney, Rice, Mobley, Trippi, & Ashby, 2001). BODY IMAGE INVESTMENT: This term refers to the re lative importance an individual places on body image in self-eva luation. For the purpose of this study, body image investment will be indicated by scores on the Self-Evaluative Salience subscale of the Appearance Schemas Inventory-Revised (ASI-R; Cash, Melnyk, & Herbosky, 2004).
109 SELF-ESTEEM: This term refers to an indi viduals evaluation of self. Although some researchers conceptualize self-esteem as a multidimensional construct, in th is study self-esteem will refer to global self-appraisals. For the purpose of this study, scores on the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) will be referred to as self-esteem. SOCIAL DESIRABILITY: This term refers to a persons tendency to portray themselves in a favorable fashion, as evidenced by a socially desirable response set. For the purpose of this study, social desirability will refer to scores on an abbreviated form of the MarloweCrowne Social Desirability Scale (MCSDS; Crowne & Marlowe, 1960; Reynolds, 1982).
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123 BIOGRAPHICAL SKETCH Jennifer Stuart was born in Springfield, Massa chusetts. She com pleted her bachelors degree at Florida Southern College with majors in psychology and special education. She then began graduate coursework at the University of Florida, earning he r masters degree in psychology in 2006. She is currently completing a pre-doctoral internsh ip at Arizona State Universitys Counseling and Consultation, and pl ans to complete her doctoral degree in August 2009. After completing her degree, Jennifer plans to return to Florida a nd begin working as a postdoctoral associate at the Univ ersity of Florida Counseling Cent er. She hopes to contribute to college student mental health and wellness throughout her career.