self-compassion and treatments for anxiety disorders: a ...€¦ · preliminary evidence suggests...

Running Head: SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375 Student Number: 500358375

1

Self-Compassion and Treatments for Anxiety Disorders:

A Systematic Review

Anders Nielsen

Student Number: 500358375

December 2018

Presented for MSc in Mindfulness-Based Approaches

School of Psychology, Bangor University

SELF-COMPASSION AND TREATMENTS FOR ANXIETY DISORDERS Student Number: 500358375

2

Acknowledgements

I would like to thank my supervisor Judith Roberts for her assistance and guidance in

developing and completing this project: your encouragement and support pulled me through.

My gratitude also goes to Andrew, Sally and Alex in Portugal, and Mike in

Amsterdam: they helped me change course and continue to inspire. For the same reasons I

want to thank Sally, Tom, Elise and Mark, my tutors at the IACTP in Cashel, Ireland, and the

IACTP-class of 2009. I owe a particular debt of gratitude to Frank, Jenny, Driekske, Heleen,

Cissy, Meino and Tom, my former mentors, colleagues and friends at the Tactus 12-

Stappenbehandeling. They guided my first steps in clinical work, illuminating the role of

compassion in both recovery and addiction treatment long before I became aware of a

theoretical foundation for this.

I would also like to thank to all of my teachers and tutors at Bangor University’s

Centre for Mindfulness Research and Practice, and my fellow-students there. A special word

of thanks goes to the members of the ‘Dharma Dogs’ peer-support group: your wisdom and

friendship proved invaluable these five years.

Finally, I would like to thank my wife Fieke and my daughters Bjørg and Sigrid, who

have been extremely patient, understanding and supportive while I continued to sacrifice

family time in the name of academic pursuits.


3

Declaration Page

This work has not previously been accepted in substance for any degree and is not being

concurrently submitted in candidature for any degree.

Signed A. Nielsen (candidate)

Date 16/12/2018

STATEMENT 1

This thesis is the result of my own investigations, except where otherwise stated. Where correction

services have been used, the extent and nature of the correction is clearly marked in a footnote(s).

Other sources are acknowledged by footnotes giving explicit references. A bibliography is appended.

A. Nielsen (candidate)

Date 16/12/2018

STATEMENT 2

I hereby give consent for my thesis, if accepted, to be available for photocopying and for inter-library

loan, and for the title and summary to be made available to outside organisations.

A. Nielsen (candidate)

Date 16/12/2018.

Word count: 9859


4

Contents

Abstract……………………………………………………………………………………….5

Introduction………………………………………………………………………..…….……6

Method……………………………………………………………………………..………...13

Results…………………………………………….…………………………………….……14

Discussion………………………………………………………………………...……….…28

Conclusions…………………………………………………………………….....…….……30

References………………………………………………………………………...…….……31

Appendices………………………………………………………………………………...…44

APPENDIX A: Tables…………………………………………………….…....44

Table 1: Primary Anxiety Disorders, Clinical Descriptions,

and Lifetime Prevalence………………………………………………..44

Table 2: Summary description of study designs, populations,

interventions and main outcomes……………………………………….45

Table 3: Summary description of disorders, populations, treatment

and (self-)compassion components in treatments under examination….49

APPENDIX B: Third wave intervention for anxiety disorders and

Self-Compassion Scale screening and selection tool…………………………..53

APPENDIX C : CRD informed research study quality assessment tool…..…..55

APPENDIX D : CASP RCT Checklist………………………….……..............56


5

Abstract

The interest in therapeutic interventions informed by mindfulness is growing. Self-

compassion is a construct that is associated with psychological well-being. It has been

identified as a potential mechanism of change of these interventions. This thesis is informed

by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

items guidelines and provides an evaluative systematic review of studies of interventions for

anxiety disorders. A systematic search of two databases was conducted for studies that used

the Self-Compassion Scale (SCS) as an outcome measure. This search yielded 115 papers and

nine studies were eligible for inclusion. Study quality was assessed by means of the Critical

Appraisals Skills Programme (CASP) Randomised Controlled Trial Checklist, and a tool

based on the Centre for Reviews and Dissemination (CRD) guidance document. It is

concluded there is preliminary evidence that interventions based on, or informed by

mindfulness may reduce symptom severity and increase self-compassion in patients with post-

traumatic stress disorder, social anxiety disorder, or related symptomatology. Furthermore,

preliminary evidence suggests that integrating self-compassion practices in treatments for

these patients may be feasible and acceptable across a wide range of populations, treatment

settings, and delivery methods. It is noted that adverse events or effects associated with self-

compassion practices were reported. A potential use of the SCS as an aid for clinicians

treating patients for substance abuse disorder is suggested. The limited generalisability and

the lack of comparability between the included studies is noted and suggestions for further

research are discussed.

Keywords: self-compassion, anxiety disorders, mindfulness, substance use disorders


6

Self-Compassion and Treatments for Anxiety Disorders:

A Systematic Review

Over the last decades a group of interventions for treatment across mental and

personality disorders known as ‘third wave’ psychotherapies has emerged, including

Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, & Wilson, 1999) and

Dialectical Behavioural Therapy (DBT) (Linehan, 1993). Building on the ‘first wave’ of

behaviour therapy, focused on operant and learning and classical conditioning and the ‘second

wave’, which focused on information processing; these psychotherapeutic methods are

supported by an emerging body of research showing their efficacy and effectiveness (Hayes,

2016; Kahl, Winter, & Schweiger, 2012; Öst, 2008). Third wave methods have shown the

potential to be effective with patients groups that were considered ‘difficult’ in the past (Kahl

et al., 2012). Although there is no suggestion of - or evidence for - the superiority of this new

approach, third wave behavioural interventions are considered to be more in line with the

current research on psychological mechanisms than ‘classical’ cognitive therapy and they are

strongly rooted in learning theory. Despite the fact that their diverse nature precludes

categorising them as belonging to one of the traditional approaches in psychotherapy (e.g.

cognitive or behavioural), they share a number of common themes and factors, such as

acceptance, cognitive (de)fusion, dialectics, spirituality, (therapeutic) relationship and

mindfulness (Hayes, 2016; Kahl et al., 2012)

Mindfulness: a Common Framework

A number of these third wave interventions have been informed by mindfulness,

which has generated considerable interest in the fields of psychiatry, psychology and

psychotherapy (Didonna, 2009). These empirically supported interventions train participants

in mindfulness meditation and encourage and support participants in the application of the

skills acquired through this training in everyday life, ameliorating mental health difficulties

and fostering therapeutic change (Baer, 2014). In this context mindfulness can be defined as

“the awareness that emerges through paying attention on purpose, in the present moment, and

non-judgementally to the unfolding of experience moment by moment” (Kabat-Zinn, 2003, p.

143). These interventions can be divided into two categories: those in which mindfulness

meditation is a central element of the curriculum, theoretical underpinning and therapeutic

approach, described as mindfulness-based programmes (MBPs); and those that share parts of

their theoretical foundation with MBPs, often including mindfulness meditation practices

described as mindfulness-informed programs (MIPs) (Crane et al., 2016).


7

A common framework for all MBPs is provided by their parent interventions:

Mindfulness-Based Stress Reduction (MBSR) (Kabat-Zinn, 2005) and Mindfulness-Based

Cognitive Therapy for depression (MBCT) (Segal, Williams, & Teasdale, 2013). MBSR

broke new therapeutic ground by integrating practices and theories derived from

“contemplative traditions, science, and the major disciplines of medicine, psychology and

education” (Crane et al., 2016, p. 990). It incorporated these in a protocolled intervention

(Blacker, Meleo-Meyer, Kabat-Zinn, & Santorelli, 2009) which aims to cultivate an attitude

of acceptance and openness to experiences, both internal and external, as they unfold. MBCT

introduced elements from cognitive therapy to the MBSR framework, aiming to acquaint and

familiarise participants with a new manner of relating to feelings, thoughts and physical

sensations known to precipitate depressive relapse (Segal et al., 2013). MBPs do not teach

participants to challenge mental and physical events, instead they aim bring about a

fundamental shift in perspective towards these events, described as “reperceiving” by Shapiro,

Carlson, Astin and Freedman (2006, p. 377). Thereby enabling participants to turn towards

their experiences in an open, curious, kind and non-judgemental manner, including those held

to be negative or difficult (Kuyken & Evans, 2014). The cultivation of self-compassion is

instrumental in developing this orientation (Feldman & Kuyken, 2011; Segal et al., 2013).

Mindfulness-based treatment can be used across a wide range of clinical areas, clinical

settings and populations (Didonna, 2009). These interventions have some important boons

compared to more established treatments: applicability across a wide range of disorders, a

cost-effective delivery format (8-12 weekly group sessions), a general absence of unwanted

side effects and a reduction of the stigma by participants that is attached to receiving mental

health treatment (Baer, 2014). Nevertheless, the researchers who developed MBCT argue that

mindfulness cannot be applied as a generic treatment approach for psychopathology and

found it can be unhelpful to some patients struggling with depression (Segal et al., 2013).

Walsh and Roche (1979) reported patients with a history of schizophrenia having psychotic

episodes after engaging in intense meditation. Furthermore, Lindahl et al. (2017) argued that

the randomised control design typically used in trials to assess efficacy and effectiveness

provides reliable and accurate information on the positive meditation-related effects of

treatment, but may not inform as adequately on adverse effects of meditation for a variety of

reasons. These researchers found in their mixed methods study of contemplative experience

that some meditation-related experiences are “typically underreported, particularly

experiences that are described as challenging, difficult, distressing, functionally impairing,

and/or requiring additional support” (Lindahl et al., 2017, p. 1). Kocovski, Segal and


8

Battista’s (2009) advocated a ‘problem formulation’ approach for developing and using

mindfulness-based approaches in psychotherapy. They proposed that mindfulness may be

most efficacious in an intervention tailored to a specific complaint, integrated with evidence-

based interventions in a theoretically consistent manner; guided by an understanding of the

mechanisms of change for the intervention, which is translated into a problem formulation

shared with participants, elucidating how mindfulness may facilitate therapeutic change.

Mindfulness and Substance abuse Treatment

The problematic use of alcohol and illicit drugs is a major public health concern: the

global prevalence of alcohol use disorders (defined as the aggregate of harmful use and

dependence) was 4.1% in 2010 (World Health Organization, 2014). In 2012 globally 3.3

million deaths could be attributed to the harmful use of alcohol, representing 5.9% of the total

number. In that year alcohol consumption takes the onus for 5.1% of the worldwide burden of

disease and injury. Additionally 0.6% of the global adult population, that is 29.5 million

people, engage in problematic drug use (defined as injecting, using illegal drugs daily or

diagnosed with drug use disorders on clinical criteria) (United Nations Office on Drugs and

Crime, 2017). Behavioural therapies are the most common forms of addiction treatment

(National Institute on Drug Abuse, 2018). Effective treatment varies, based on the nature of

the substance being abused and characteristics of the patient, taking associated medical,

psychological and socio-economic problems and characteristics into account. The earlier

treatment is offered in the addiction process, the likelier it is to result in a positive outcome, as

is the case with other chronic diseases. The relapse rate of 40-60% of patients is also on a par

with other chronic diseases (e.g. Type 1 diabetes and hypertension). A range of tailored

treatment program and follow-up options is available, including both medical and mental

health services.

A recent systematic review and meta-analysis by Li, Howard, Garland, McGovern and

Lazar (2017) found that mindfulness treatment is a promising intervention for substance

misuse, but that more research was needed into the effectiveness across treatment settings and

patient populations, as well as further research into the potential mechanisms of change.

Currently two empirically supported, manualised mindfulness-based interventions for

substance abuse and relapse prevention exist. Mindfulness-Based Relapse Prevention

(MBRP) (Bowen, Chawla, & Marlatt, 2011) is a MBP designed as an after-care program

following treatment for addictive behaviours. It integrates the theory and practices rooted in

cognitive-behaviour therapy (CBT) from Relapse Prevention (RP) (Marlatt & Donovan, 2008)

with mindfulness-based techniques in the framework provided by MBCT. Mindfulness-


9

Oriented Recovery Enhancement (MORE) (Garland, 2013) is a MIP aimed to support all

individuals wishing to extricate themselves from addiction, intended for delivery across a

variety of treatment settings and populations. It integrates principles and techniques drawn

from CBT, positive psychology and mindfulness training.

Building on the theoretical foundations of RP for alcohol and drug problems

(Witkiewitz & Marlatt, 2009) and MPBs (Baer, 2003; Bishop et al., 2004; Hölzel et al., 2011;

Shapiro et al., 2006), Penberthy et al. (2015) proposed psychological and physiological

mechanisms of action for MBRP. They noted that further research into which participants

responded to MBRP and why, is needed for tailoring the implementation of this intervention.

Witkiewitz et al. (2014) reviewed these foundations and hypothesised mechanisms of change

by which mindfulness training moderates the relapse process, and recommended studying

how these treatments have been adapted for specific settings and populations. They

hypothesised that mindfulness training may directly moderate the relapse process by

“increasing awareness, decreasing automatic non-mindful responding and judgmental

thinking, and increasing kindness and self-compassion” (p. 517). In comparison with the

hypothesised mechanisms of change for MBPs self-compassion stands out, because only

Kuyken et al. (2010) explicitly identify it as a mechanism of change for the parent

interventions of MBRP. In keeping with its roots in Buddhist and Western psychology the

cultivation of compassion is considered central to the potential for healing that MBPs offer

participants. Feldman and Kuyken (2011) have outlined how the cultivation of compassion by

participants is a central element in MBPs, even though it is not explicitly taught in the

curricula of their parent interventions. Segal, Williams and Teasdale (2013) decided not to

include formal compassion or loving-kindness practices in the MBCT curriculum. They

feared that any invitation to practice loving-kindness or compassion meditation might

immediately cause participants to revert to deeply engrained habits, such as considering

themselves to be unlovable, unworthy or imperfect.

Loving-kindness meditation (LKM) (Salzberg, 2011) is a core practice from the

Theravada Buddhist tradition. The Pali term mettā is often translated into English as ‘loving-

kindness’. Mettā is one of the brahmavihāras, the Buddhist virtues referred to as the “Four

Immeasurables” in English (Bodhi, 2005). Cultivating mettā by means of LKM, fostering an

attitude of kindness towards oneself and others, benefits both the individual practitioner and

society as a whole (Koster, 2012). Compassion, karunā in Pali, is another brahmavihāra.

Compassion meditation helps practitioners cope with pain, adversity and suffering in

themselves and in others, and has similar benefits for society as a whole.


10

Self-compassion: Construct and Practice

Self-compassion is a construct which is significantly associated with mental health and

psychological well-being. It allows both a kinder attitude towards and more understanding of

oneself, and more perspective on personal experience (Neff, 2003b). Neff’s definition of

“self-compassion entails three main components, each of which has a positive and negative

pole that represents compassionate versus uncompassionate behavior: self-kindness versus

self-judgment, a sense of common humanity versus isolation, and mindfulness versus over-

identification.” (Neff, 2016, p. 265). These components are interwoven aspects of one cyclical

development process, interacting and enhancing each other: on a par with intention, attention,

and attitude, the “axioms of mindfulness” hypothesised by Shapiro et al. (2006) to be the

mechanisms of change underlying all MBPs. The Self-Compassion Scale (SCS) (Neff, 2003a;

Neff, 2016) is a validated, theoretically coherent instrument for measuring self-compassion,

based on the aforementioned definition of self-compassion. High levels of self-compassion as

measured by the SCS have been linked to increased psychological wellbeing and

ameliorations in mental health (Neff, 2003a; Neff, Rude, & Kirkpatrick, 2007). The six

subscales of the SCS correspond with the poles Neff identified as representing compassionate

versus uncompassionate behaviour. The Self-Compassion Scale-Short Form (SCS-SF) is an

abbreviated, reliable alternative with the same factorial structure (Raes, Pommier, Neff, &

Van Gucht, 2011).

The final two sessions of the MBRP curriculum (Bowen et al., 2011) include loving-

kindness mediation. During these final sessions participants are encouraged to select a number

of practices from the curriculum, and incorporate them in a personal program of mindfulness

practices to be sustained and incorporated into their lives after the final session. Bowen,

Chawla and Marlatt (2011) argue that the attitudes loving-kindness practice cultivates are

central to recovery and healing, given the pervasiveness and palpability of self-criticism and

self-judgement in persons with a history of substance abuse and their frequent difficulties in

forgiving themselves for the impact of this abuse on their lives. Garland (2013) incorporated a

combined loving-kindness and compassion meditation in MORE for similar reasons; adding

that the experience of the positive emotions this practice generates may replenish some of the

endogenous neurochemicals involved in self-regulation and adaption to stress. These

neurochemicals may be depleted by chronic substance abuse.


11

Substance Abuse and Anxiety Disorders

An investigation of patterns of use of mental healthcare and treatment (Harris &

Edlund, 2005) found that half of the respondents who met the criteria for substance abuse

disorders (SUD) at some point in their lifetime, also met the criteria for a mental disorder at

one point in their life, and vice versa: mental and substance use disorders co-occur at a high

rate. Thirty to sixty percent of people with SUD have one or more co-occurring mental

disorders, which should also be addressed in effective treatment (Moos, 2009). Several co-

occurring disorders are exceedingly common in patients presenting themselves for addiction

treatment: mood disorders (40.5%), anxiety disorders (26.4%), post-traumatic stress disorder

(25%), severe mental illness (17.3%), anti-social personality disorder (18.3%) and borderline

personality disorder (17.4%) (McGovern, Xie, Segal, Siembab, & Drake, 2006). Practice

patterns for these patients vary widely (Moos, 2009). Integrated treatment models combining

care for co-morbid disorders seem to be most effective, but little is known about best practices

and critical components of dual-diagnosis treatment programs.

Anxiety disorders are the most prevalent psychiatric problems in the adult population

(Kessler et al., 2005). An overview of the six primary anxiety disorders, their clinical

description and their lifetime prevalence appears in Appendix A, Table 1. The fight or flight

response (Cannon, 1929) is a normal physical reaction to the threat of danger, later the

“freeze” response was added in models of the key behaviours that occur when humans face a

real or perceived threat (Schmidt, Richey, Zvolensky, & Maner, 2007). The fight, flight or

freeze response triggers a wide range of physical, cognitive and behavioural reactions in

preparation of responding to the threat; including the secretion of stress hormones, an increase

of heartbeat, breathing rates and muscle tension, and the concurrent the experiencing of fear

in the brain: a narrowing of the focus of attention, the occurrence of negative or even

catastrophic thoughts, difficulty concentrating, and pacing or fidgeting (Daley & Moss, 2003;

Greeson & Brantley, 2009). Anxiety disorders can occur if the normal and adaptive responses

to a threatening situation are triggered in inappropriate situations, persist well after the threat

has passed, or lead to the restriction of activities through avoidant behaviour.

A belief in the anxiolytic effect of substance use is deeply engrained in our culture. In

ancient times Hippocrates (1886, p. 269), the father of Western medicine, advocated drinking

wine mixed with an equal measure of water as a remedy against “anxiety and terrors”. In his

tension reduction hypothesis, Conger (1956) proposed that alcohol is used to reduce tension

and anxiety, and that its consumption may be continued to avoid these: a reinforcing process

of self-medication. Modified versions of this theory are still relevant to our understanding of


12

alcoholism (Young, Oei, & Knight, 2010). Later research found the relationship between

anxiety disorders and substance abuse to be close, varied and complex. Some may appear to

precede substance dependency, indicating self-medication as a possible causal effect; others

may appear to be the result of the worsening of anxiety symptoms into a pathological

condition as a result of chronic substance abuse (Daley & Moss, 2003). For instance,

agoraphobia and social phobia often precede problematic alcohol use, possibly indicating

attempts at self-medication. Whereas panic and generalised anxiety disorder often seem to

follow the onset of alcohol problems (Kushner, Sher, & Beitman, 1990). Kusher et al. (1990)

argued that the negative consequences of chronic alcohol abuse may themselves be

anxiogenic: anxiety symptoms can manifest as a result of SUD (SAMSHA, 2005). Fear and

anxiety are also common threads in self-help groups attended by persons recovering from

substance abuse (e.g. Alcoholics Anonymous, 2001; Narcotics Anonymous, 2008).

Furthermore, the prevalence of SUD in the families of people suffering from anxiety disorders

is significantly higher compared to the general population (Daley & Moss, 2003). A variety of

strategies and interventions are used to treat anxiety disorders. Comparable to treatment

strategies designed for SUD, cognitive approaches aim to teach patients to realistically assess

difficult or threatening situations and address flawed thinking. Behavioural approaches are

aimed at specific target behaviours (e.g. phobias), the improvement of social skills and

encourage and the pursuit of alternative, non-triggering activities. Lifestyle strategies aim to

improve dietary and personal habits, and teach the use of breathing, meditation or relaxation

techniques.

The desire to avoid the inner experience of fear is a characteristic of anxiety disorders

(Greeson & Brantley, 2009). The psychobiological nature of the responses triggered in

patients and the models for maladaptive cognitive response to their inner experience of fear,

shares much common ground with the those described in the theoretical foundation for MBPs.

Self-compassion: Instrument and Indicator

The emerging body of research on the manualised, evidence-based mindfulness

treatments for SUD and anxiety disorders identify self-compassion as an important construct

and potential mechanism of change for these interventions. Van Dam, Shepard Forsyth and

Earleywine (2010, p. 123) described self-compassion as “a robust and important predicator of

psychological health that may be an important component of MBIs [Mindfulness-based

Interventions] for anxiety and depression”. However, further research is needed in order to

effectively adapt treatment across populations and treatment settings (Li et al., 2017). For fear

of triggering vulnerabilities also common in patients with anxiety disorders the developers of


13

MBCT made an informed decision not to include self-compassion practices in their

curriculum. On the other hand loving-kindness and compassion meditation practices are

included in the curricula for the manualised, evidence-based treatments for SUD that

incorporate mindfulness. Both Marlatt, Chawla and Bowen (2011) and Garland (2013)

describe how observing and experiencing the initial difficulties patients encounter when first

introduced to these practices (which incorporate explicit instructions for cultivating self-

compassion), are an important and integral part of the curriculum.

Given the high prevalence of patients with co-existing substance abuse and anxiety

disorders and the fact that many patients with SUD present anxiety symptoms,

the present work aims to inform the development of adaptations of MBPs and MIPs for SUDs

by examining the relationship between self-compassion and treatment outcomes in trials of

interventions for anxiety disorders.

Method

Literature search

In March 2018 the author searched the electronic databases ProQuest and Web of

Science for articles published up to December 2017. The search aimed to identify studies of

interventions for anxiety disorders which use the Self-Compassion Scale as an instrument.

The search string employed was “anxiety disorder* AND Self-Compassion Scale AND

mindfulness”, in combination with filters for peer-reviewed articles, published in English.

Searching ProQuest the databases selected were: Periodicals Archive Online, PILOTS:

Published International Literature On Traumatic Stress, ProQuest Historical Newspapers:

The Guardian and The Observer, ProQuest Social Sciences Premium Collection, PsychINFO

and Social Science Premium Collection; 109 records were retrieved and documented. A

search of the Web of Science database employing the same search string resulted in 17

records, which were retrieved and documented. In addition the author hand searched the

research publications (Neff, 2018) listed on the website of Kristin Neff, who developed the

SCS, using the same criteria in March 2018; this yielded a further 26 records. Finally, Dr.

Neff was approached via e-mail, requesting information regarding unpublished literature. This

did not yield any additional records. The author read titles and abstracts for all records

documented in this manner and retrieved the entire article if there was an indication of an

experimental study examining an intervention for an anxiety disorder that used the Self-

Compassion Scale (SCS) as an instrument.


14

Selection of studies

Studies were included in this review if they (a) had adult participants with a clinical diagnosis

of an anxiety disorder or presenting related symptoms; (b) examined an intervention for

anxiety disorders which incorporates the exploration of inner experience; and (c) were

published in peer-reviewed journals in English. Studies were excluded if they (a) did not asses

self-compassion using the SCS as an instrument; (b) included children and minors as

participants; (c) were systematic reviews or meta-analyses. Comparators were not included as

a criterion for selection. The primary outcome measures examined in the present review are

variations in (a) anxiety symptom severity and (b) self-compassion levels at post-treatment

and follow-up assessments, and (c) associations between these two outcomes. Secondary

outcome measures examined are (a) feasibility of the intervention and (b) participant

acceptability of the intervention.

The author read and assessed all retrieved studies for inclusion, using the screening

tool included as Appendix B. A flow chart illustrating the screening and selection process for

this review appears in Figure 1.

Data extraction and synthesis

The risk of bias of all included studies was additionally assessed with a tool based on

the Centre for Reviews and Dissemination (CRD) guidance document for undertaking

systematic reviews (2009) and the results tabulated. This tool is included as Appendix C. Data

were extracted from the selected studies with the Critical Appraisals Skills Programme

(CASP) Randomised Controlled Trial Checklist (2018), which is included as Appendix D.

The pre-specified outcomes were tabulated and discussed in a narrative synthesis. Due to the

heterogeneous nature of the data statistical synthesis was considered inappropriate, precluding

meta-analysis.

Results

Characteristics of the included studied

Nine studies met the inclusion criteria for the current review. Their designs, populations,

interventions and main outcomes are summarised in Appendix A, Table 2. Five of the

included studies were designed as a Randomised Controlled Trial (RCT), which is considered

to provide the most reliable evidence when examining the impact of interventions (Higgins &

Green, 2011). Four studies were not designed as RTCs. Although not on a par with RCTs in

the hierarchy of evidence, the within-subject nature of the data from the three uncontrolled

non-RCT studies provides strong evidence when examining the relationships and associations

between dependent variables.


15

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-

Analyses) flow diagram (Moher, Liberati, Tetzlaff, & Altman, 2009). Studies

examining interventions for anxiety disorders incorporating the exploration of

internal experience.

Five studies examined interventions for Post-Traumatic Stress Disorder (PTSD) or

trauma-related symptoms and four investigated treatment aimed at SA Disorder (SAD) or

related symptomatology. Sample sizes ranged from 6 to 65. The characteristics of the

interventions under examination varied widely, as did their methods of delivery. Five of the

interventions incorporated either explicit (self-)compassion practices, exercises or techniques,

or LKM. Two of these were adaptations of exposure, a key element in most CBT treatments

for anxiety disorders (Rodebaugh, Holaway, & Heimberg, 2004). Treatment was delivered

individually in four studies, in a group format in another four studies, and one study examined

an intervention delivered by means of a workbook. A summary description of targeted

disorders, populations, treatments and (self-) compassion components incorporated in the


16

treatments under examination for the included studies is provided in Appendix A, Table 3.

This review will first present a brief summary of the included studies ordered by

design, subsequently summarising treatment delivery and outcomes for these studies arranged

by the disorder they address. The potential for bias of all included studies assessed by means

of the CRD tool appears in Appendix A, Table 4.

Summary of RCT designs

Four of the five included RCTs randomised participants directly to active control

groups, one to a waitlist control group. All researchers reported on ethics and informed

consent procedures, and formulated clear inclusion criteria regarding the anxiety disorder or

related symptomatology and the intervention under examination. Jazaieri, Goldin, Werner,

Ziv and Gross (2012) and Koszycki et al. (2016) recruited their clinical samples through

referrals from mental health care providers, and through self-referrals via advertising at these

facilities and on-line. Hoffart, Øktedalen and Langkaas’ (2015) experiment was the only RCT

situated outside the USA. This Norwegian study exclusively recruited participants who had

been referred to an in-patient treatment program for PTSD. Consequently it was the only RCT

to preclude self-selection bias, as the others all included participants who self-referred.

The RCTs that examined clinical samples all reported on inclusion or exclusion

criteria with regards to ongoing psychotherapy, psychotropic medication and co-morbid

psychopathology or related symptoms. Hoffart et al. (2015) and Koszycki et al. (2016)

formulated criteria around suicide risk. Jazaieri et al. (2012) and Hoffart et al. (2015)

excluded those engaged in concomitant psychotherapeutic interventions, and participants

using psychotropic medication. Koszycki et al. (2016) included participants with stable

medication types and doses, provided these did not change after randomisation. The studies

examining MBPs excluded participants with ongoing meditation practices. Additionally

Koszicky et al. (2016) excluded those with a regular yoga practice, and Jazaieri et al. (2012)

excluded participants who had previously completed a MBSR course. Hoffart et al. (2015)

and Koszycki et al. (2016) both reported on blinding and concealment during the allocation of

participants across treatment groups. They also specified the randomisation technique

employed, as did Jazaieri et al. (2012). Held and Owens (2015) and Valdez and Lily (2016)

provided no information about their randomisation process, impeding assessment of potential

confounding through allocation and performance bias.

Two RCTs examined specific target populations, thereby limiting the generalisability

of their findings. Valdez and Lily (2016) recruited female participants from the Psychology

Department of a university and local community who had been exposed to trauma. They


17

advertised locally and contacted participants in earlier studies conducted at that university.

They excluded those whose trauma exposure had occurred before they were 16 years old,

those whose trauma had occurred within three months of recruitment, and those for whom

participation might have resulted in additional stress or encumbered study results. Held and

Owens (2015) recruited their participants from a transitional housing facility for homeless

veterans, with an intermediate reading level as the only criterion for eligibility. Participants in

this study continued to receive their regular treatment at an out-patient clinic for veterans and

at their housing facility. This included psychotherapy, pharmacotherapy, and attending

support and self-help groups.

Taken together the eligibility criteria denote considered efforts in four RCTs to reduce

confounding dependent variables and optimise internal and external validity. Held and

Owens’ use of a single inclusion requirement appears less rigorous by comparison. On the

other hand their target population is much more difficult to access for both researchers and

mental health care providers (van den Bree, Bonner, Taylor, & Shelton, 2009). Another

indication of the methodological strength of the included studies is how they seek to minimise

the risk of attrition bias and missing data affecting the validity of their results. Three RCTs

used intent-to-treat (ITT) analysis (Fisher et al., 1990) (see Appendix A, Table 4). In Held and

Owens’ study (N = 47) 43% of participants dropped out during the treatment period, the

reasons were not reported. Their analysis used the sample (n= 27) that completed all

assessments; compared to ITT-analysis this approach is considered to be less effective in

eliminating bias (Higgins & Green, 2011). On this aspect of quality assessment Valdez and

Lily’s RCT stands out, because they provided neither a flowchart of their participants, nor

equivalent data. Thereby precluding assessment of the risk of attrition bias and missing data

affecting the internal and external validity of their results. A further indicator of

methodological rigour is the reporting of observed means, standard deviations and other

descriptive statistics for continuous variables. Jazaieri et al. (2012), Koszycki et al. (2016),

and Held and Owens (2015) provided these data. Hoffart et al. (2015) and Valdez and Lily

(2016) did not.

Summary of non-RCTs designs

Kearney et al. (2013) were the only researchers in the non-RCT category to examine a

clinical sample. This consisted of veterans with current PTSD receiving treatment at an urban

veterans hospital in the USA. Some of the participants were referred by health-care providers

and others referred themselves. These researchers did not report on their method of

recruitment. Boersma, Håkanson, Salomonsson and Johansson (2015) recruited university


18

students experiencing social anxiety (SA) at a Swedish university, advertising both on campus

and on-line. In Norway, Hjeltnes et al. (2017) recruited young adults presenting problems

with SA or SAD via referrals from a university mental healthcare centre and self-referral.

They advertised in the same manner as the Swedish researchers, and pre-screened participants

by telephone. They formulated exclusion criteria around co-morbid serious mental disorders,

suicidality, and substance abuse or SUD. Thereby reducing the threat of selection bias

affecting the internal validity of their findings. Hjeltnes et al. (2017) excluded persons with a

history of severe trauma, and Kearney et al. (2013) those with a history of psychotic disorder.

Boersma et al. (2015) were the only researchers in this category to exclude participants

engaged in concomitant psychotherapy, or recently initiated pharmacotherapy. All of the non-

RCT studies reported on the methods of statistical analysis they employed to assess outcomes,

clinical significance, correlations between outcomes and compare treatment outcomes.

Hjeltnes et al.’s (2017) was the only study to use ITT analysis in this category, strengthening

the generalisability of their findings. Boersma et al. (2015) did not report on either ethics

approval or consent, reported on ethics approval only. Hjeltnes et al. (2017) and Kearney et al.

(2013) reported on both.

Beaumont, Galpin and Jenkins’ (2012) study design stands out in the non-RCT

category, because it included an active control group and randomisation of participants across

treatments. They recruited participants referred by agencies in the UK for CBT after a trauma-

related incident. This comparative outcome study did not report on participant selection,

screening or inclusion and exclusion criteria, or consent, although it did report on ethics

approval. The participants were randomised between two treatment conditions, stratified by

the type of trauma experienced. This study was categorised as a non-RCT, because it

examined a “non-random purposive sample” (p. 34) and did not provide information on their

method of randomisation, nor on the inclusion and exclusion criteria.

Outcomes for studies examining SAD

Boersma et al. (2015) used a replicated single case design to examine the effects of

Compassion Focussed Therapy (CFT) (Gilbert, 2010) in reducing shame, self-criticism and

SA and increasing SC; additionally reporting on both treatment satisfaction and whether

participants experienced treatment helped them cope with SA and increase SC. CFT is an

approach within CBT that “is rooted in an evolutionary, neuro- and psychological science

model” (p. 9), integrating traditional Buddhist concepts and practices around compassion. The

participants (N = 6) were university students experiencing de facto life-long problems around

SA and shyness. Treatment consisted of an adaptation of CFT as presented by Henderson &


19

Gilbert (2011), integrating elements from other self-help formats inspired by Gilbert (2010).

It was manualised and delivered in eight weekly, one hour sessions by psychology students

finalising their clinical training. These were supervised by a psychotherapist, treatment

adherence was not assessed. This study used self-report instruments to measure SA, social

interaction, SC and depression, in addition to a diary to track changes in shame, self-criticism

and SC; and a final treatment evaluation questionnaire. Measurements began with a baseline

period, followed by weekly measurements during treatment and a 2-4 week follow-up period.

Data were analysed using the PEM approach (Ma, 2006), suitable for examining treatment

effect in single subject-designs, and a Reliable Change Index (RCI) was calculated (Jacobson

& Truax, 1991) for the SCS and SA symptom measures. PEM scores indicated a strong effect

of treatment for five out of six participants on SC; a questionable effect on shame was

reported for half of the participants (three), a strong effect for two participants and a moderate

effect for one. Additionally, a questionable effect of treatment was reported for half of

participants on self-criticism, with a moderate effect reported for two participants and a strong

effect for one. Further analyses indicated reliable change for five out of six participants on

SC. Results for SA symptoms were mixed, with reliable change reported for only two

participants on one of the outcome measures, and for half of the participants on the other. The

participant’s perception of improvement in coping with SA was more positive: half of

participants reported having improved “a lot” and half “somewhat”, four participants reported

being “very satisfied” with treatment and the remaining two were “quite satisfied” (Boersma

et al., 2015, p. 92-4).

The replicated single case design chosen for this study, although appropriate for a pilot

study, limits the generalisability and external validity of its results. On the other hand this

design inherently allows inferences of cause and effect relationships between variables. This

study could have been strengthened by extending the baseline and follow-up measurement

periods, and including non-self-report measures.

Hjeltnes et al. (2017) conducted an open trial of MBSR for young adults (N = 53)

with SAD. Four of the seven authors of this study delivered treatment. All classes were

taught by at least one clinical psychologist with formal training as a MBSR teacher;

supervision and treatment adherence were not reported on. This study used self-report

measures to assess changes in levels of mindfulness, self-esteem and SC one week before the

intervention, mid-treatment, and after the last class of a MBSR program. The drop-out rate for

this study was 15%. ITT analyses yielded effect sizes that were large for SAD symptoms


20

(Cohen’s d = 0.80), moderate for global psychological distress (d = 0.61) and self-esteem (d =

0.63), and moderate to large effects for SC (SCS subscales d = 0.79 – 1.16). The largest

effect sizes were reported for over-all SC (d = 1.16), and the self-kindness (d = 1.03) and

common humanity (d = 0.96) subscales. A clear majority of the participants in the ITT sample

within the in the clinical range for SAD symptoms, reported reliable and clinically significant

change (34%), or reliable change (27%) on these symptoms. This study reported a significant

negative association between changes in SAD symptoms and SC (Pearson’s r = -0.46), as

well as a significant positive association between SC and self-esteem (r = 0.64).

While it was well conceived, this study’s non-experimental design limits the potential

for generalisation of its results and inferring causal relationships from them. On the other

hand, the large sample size and use of ITT analysis strengthen the internal validity of its

findings. This study could have been strengthened further by including non-self-report

measures, a long term follow-up measurement, and excluding the authors from treatment

delivery.

Jazaieri et al.’s (2012) RCT also examined the efficacy of MBSR in treating SAD.

They allocated participants (N = 56) diagnosed with SAD across two active treatment groups:

MBSR (n = 31) and AE (n = 25). In choosing AE as the active comparison condition this

study aimed to “match non-specific factors of MBSR, while having the absence of active

ingredients in MBSR” (i.e. meditation practice, group interaction and psycho-education). It

matched the time and effort required for group and individual components, monitoring

practice and whether participants encountered obstacles on a weekly basis by telephone.

Participants in both groups were asked to record both the frequency and duration of their

group and weekly practices. MBSR was taught by instructors with between 10 and 20 years of

experience, their training, supervision or treatment adherence were not reported; no

information was provided about the aerobics instructors. This study only reported on the

outcomes of statistical analyses of treatment completers, as these were equivalent to those for

the ITT-sample. Two groups of non-randomised participants were included in analyses of

clinical significance: Healthy Controls (HC) (n = 48) and untreated participants with SAD

(UT) (n = 29). The UT group consisted of participants in separate RCT with very similar

inclusion and exclusion criteria (Goldin et al., 2012). The researchers assessed clinical and

well-being symptoms with self-report instrument pre-intervention, post-intervention and three

months after the intervention for participants in the active treatment groups, and at two times

16 weeks apart for the UT group; data collection for the HC group was not specified.

Repeated measures analyses found comparable significant changes for the active treatment


21

groups compared to the HCs: both treatments were associated with reductions in SA and

depression, and increases in subjective well-being; these changes were maintained at the 3

month follow-up. No significant difference was found between both active groups on either

clinical (χ2: ps > .09) or well-being measures (χ2: ps > .1). Additional analyses compared the

active treatment groups to the UT group: for the MBSR-group they yielded a significant

decrease in symptoms on most clinical measures; and a significant increase on some well-

being measures, but not for SC and self-esteem. Comparing the AE and UT groups, these

analyses found significant decreases in clinical symptoms for SA and improved SC; no

significant changes were reported for the other clinical and well-being measures. The reported

drop-out rates were 16% for the MBSR group and 8% for the AE group. The average

individual practice time reported for both groups was 3.4 hours per week.

The matching of time and effort required from participants across active treatment

groups, combined with its sample size and the inclusion of an untreated group of participants

with SAD, make this the most methodically robust of the included studies. However, the fact

that participants in the UT group were not directly randomised precludes making direct

inferences from the results that compare this group of participants to those allocated to active

treatments. This study could have been strengthened further by including assessment of

treatment adherence, direct randomisation of all participants, and reporting on allocation

concealment and administration blinding.

Koszycky et al. (2016) investigated the initial efficacy and feasibility of Mindfulness-

Based Intervention for SA Disorder (MBI-SAD), assigning the predominantly white female

participants (N = 39) to either active treatment (n = 21) or waitlist control (n = 18). One of the

authors delivered treatment, which incorporates mindful exposure, LKM and self-compassion

meditation. She reported having formal training in delivering MBPs, expertise in treating

patients with SAD and a personal mindfulness practice. Treatment efficacy was assessed

using a combination of clinician-rated measures and self-reported measures; with the former

administered by assessors blind to group allocation. SC was measured with the SCS-SF. The

number of treatment completers was used to assess feasibility. Home practice compliance was

monitored by requesting participants to keep a daily meditation log. The researchers found the

MBI-SAD group demonstrated significantly greater improvement at the end of treatment

compared to the WL group on SA symptom severity, social adjustment and SC. These

treatment gains were maintained at the 3-months follow-up. The increase in SC correlated

negatively with the end of treatment scores for both measures of SA symptoms (r = -0.57 and

r = -0.53) and clinical global impression (r = 0.54). MBI-SAD was found to be both feasible


22

and acceptable: 81% of the participants attended 8 or more out of 12 sessions. The researchers

estimated that on average participants spent half an hour per day on formal mediation practice

at home. Session attendance correlated significantly with engagement in formal practice (r =

0.73) and improvements on post-treatment scores for one of the measures of anxiety

symptoms (r = - 0.49), social adjustment (r = -0.60) and SC (r = 0.53). The time participants

engaged in formal mediation practice correlated with post-treatment SC scores (r = 0.56) and

the total number of days participants engaged in mindful exposure correlated with end of

treatment scores on social adjustment (r = -0.54). More than two thirds of participants in the

MB-SAD group (71%) intended to continue to “engage in some form of formal practice” at

the conclusion of treatment. The follow-up assessment revealed a considerable decrease in the

time they engaged in formal meditation practice compared to the 12-week program.

Notwithstanding its lack of an active control arm, this was a rigorously designed RCT

that combined clinician- and self-rated outcome measures. Well-conceived for a preliminary

investigation of treatment efficacy and feasibility, this study adequately addressed nearly all

aspects of quality assessment selected for this review. On the other hand, the size and

representativeness of its sample limit the generalisability of this study’s findings. It could

have been strengthened further by using an active, rather than a WL control group, controlling

for both the Hawthorne effect and being in a supportive group, thereby improving external

validity. Excluding the authors from treatment delivery would have strengthened this study’s

internal validity as well.

Outcomes for studies examining PTSD

Two studies employed non-RCTs designs to examine interventions for PTSD patients

and trauma-victims. Beaumont et al. (2012) assigned participants (N = 32) who had

experienced a traumatic incident across two groups, receiving either 12 individual sessions of

CBT (n = 16), or CBT coupled with Compassionate Mind Training (CMT) (Gilbert & Procter,

2006) (n = 16). One of the authors, a qualified cognitive behavioural psychotherapist,

delivered treatment. Her training in CMT, supervision and treatment adherence were not

reported on. CMT is the therapeutic technique at the core of CFT (Leaviss & Uttley, 2015).

This study used self-report measures of anxiety and depression, subjective-distress, and SC

administered pre- and post-therapy; treatment adherence, completion and compliance were

not reported on. This study used the SCS-SF to measure SC. Analysis of variance of these

data found highly significant post-therapy reductions of avoidant behaviour, intrusive

thoughts, hyper-arousal symptoms and anxiety for both groups, without finding significant

differences between these groups. Post-therapy levels of SC for both groups also displayed a


23

highly significant increase, with the combined CBT/CMT reporting significantly higher

overall levels of SC compared to the CBT-only group.

Although its design is appropriate for an initial exploration of the effect of integrating

a new technique into CBT, this study has several limitations in addition to those around

participant selection and randomisation noted earlier. Only the participants in the combined

CBT/CMT group were informed about one of the specific goals of the intervention: to

“develop empathy for themselves and acceptance of their distress” (Beaumont et al., 2012, p.

34). As a consequence the outcome measures on the SCS are vulnerable to confounding

through participant bias, limiting their internal validity. Excluding the authors from treatment

delivery and including non-self-report measures would have further strengthened this study’s

internal validity.

Kearney et al. (2013) conducted an open trial of LKM for veterans with PTSD in the

US. The veterans (N = 42) followed a 12-week LKM course taught by experienced meditation

teachers. Their qualifications, training, supervision and treatment adherence were not reported

on. This meditation course was delivered adjunctive to the usual care at a veteran's hospital.

The study measured life-time traumatic events, PTSD symptoms, depression, SC,

compassionate love and mindfulness skills at a baseline assessment, conclusion of treatment

and three months post-treatment. Statistical analyses included calculating standard mean

differences, RCI calculation, and mediation analyses. Eighty-eight percent of participants

provided data at the post-intervention assessment and 81% at the three months follow-up.

The researchers found LKM to be highly acceptable for veterans, with 74% of participants

attending 9-12 classes and 86% five or more. They reported large effect sizes for SC, both

post treatment (Cohen’s d = 0.80) and at three months follow-up (d = 0.92). Additionally they

found large and medium effect sizes for PTSD symptoms (d = -0.75) post treatment, and at

the three months follow-up (d = -0.89). Regression equations found that changes in SC scores

significantly mediated changes in PTSD symptoms both between baseline and post-

intervention, and baseline and the three months follow-up.

This was a well-designed open pilot study that provides detailed information on mean

scores and effect sizes for its measures and the correlations among these variables. However,

as the intervention was delivered adjunctive to treatment as usual, concurrent therapy may

have confounded the measured treatment effects. Additionally, over half of the participants

had previously participated in a MBSR program. This study could have been strengthened

further by including an active control arm, adding non-self-report measures and excluding

participants who had completed a MBI program.


24

Three RCTs investigated the role of SC in treatment for participants with PTSD or

victims of intentionally caused trauma. Valdez and Lily (2016) studied the effect that analytic

and experiential processing modes, and the SC components of self-kindness, mindfulness and

common humanity have on the trauma processing outcomes of negative affect, positive affect,

and anxiety. Traditional CBT typically has an analytical focus, whereas third-wave

interventions have an experiential focus. Their study used a combination of self-report and

clinician administered measures of PTSD symptom severity, depression, SC, and positive and

negative affect, partially administered by one of the authors before and after an individual

laboratory session. The researchers took baseline measures of SC, trauma history and PTSD

severity via an online questionnaire a number of days or weeks prior to the laboratory session.

Their exclusively female sample (N = 63) was assigned across two experimental conditions

and a control group (all ns = 21). Participants in the experimental condition groups received

either an experiential processing, or an analytic processing induction, the control group

received neutral instructions. Subsequently all participants were exposed to an identical range

of scenarios. The various modes of processing were induced by a blinded research assistant.

This study did not report on treatment adherence and the training, nor on qualifications and

supervision of the persons involved in the experimental procedure for the study. Correlation

analysis of baseline measurements for the SCS subscales found an association between

greater scores on two components of SC (self-kindness r = −0.40; mindfulness r = −.39) and

less post-traumatic stress symptom severity. At this point greater self-kindness was associated

with less hyperarousal (r = −.43) and less emotional numbing (r = −.50), as was mindfulness

(r = −.36 and r = −.47 respectively). After trauma processing greater self-kindness was

associated with higher positive affectivity (r = .50) and higher anxiety levels (r = .48); and

greater common humanity also correlated with higher anxiety levels (r = .62). This study

reported correlations for individual treatment groups after trauma processing as well, without

providing descriptive statistics. In the analytical processing group it found greater self-

kindness was associated with less negative affectivity; and mindfulness was associated with

less negative affectivity, less anxiety and greater positive affectivity. In the experiential

processing group greater self-kindness was associated with positive affectivity and higher

anxiety levels, and greater common humanity also associated with higher anxiety levels. In

the control group greater mindfulness and self-kindness were associated with less anxiety and

negative affectivity.

This RCT specifically examined the individual impact of a SC-focussed treatment

component and its CBT equivalent, combining three active treatments in a robust design that


25

used both clinician- and self-rated measures. However, the generalisability of its findings is

severely limited by selecting an exclusively female sample. This study could have been

strengthened further by assessor blinding, and reporting on and assessing of the randomisation

procedure.

Held and Owens (2015) investigated the effect of a four-week workbook training on

PTSD-symptom severity and trauma-related guilt cognitions in homeless veterans (N = 47).

They allocated participants across two active interventions: SC training (n = 13) incorporating

SC-exercises commonly used in other interventions (e.g. CMT); and stress-inoculation

training (SI) (n = 14), which incorporated exercises common to this type of training (e.g. deep

breathing, progressive relaxation and visualisation). This study only reported outcomes for the

participants that completed all assessments (n =27) of trauma-related guilt, PTSD symptoms

and SC. These were administered pre-, mid- and post-training. Participants were encouraged

to read the workbooks and practice the exercises they contained for a minimum of 5-15

minutes each day, at a meeting that started the self-administered treatment. Both interventions

contained breathing, visualisation and awareness exercises, prompting the researchers to make

some adaptations in order to avoid overlap. The researchers reported a significant increase in

SC (d - 1.033) and decrease in trauma-related guilt (d = 2.792) for both groups between the

pre- and post-intervention assessments; PTSD-severity did not differ significantly.

In addition to examining the efficacy of SC training, this pilot study investigated the

feasibility of a cost-effective means of delivering treatment to a disadvantaged population.

The internal validity of its results were enhanced by a concerted effort to match the time and

effort across both interventions and to avoid overlap between the included exercises.

Nonetheless, it could have been strengthened further by including a WL control group, and

eliminating a confounding factor by excluding participants engaging in concomitant psycho-

and pharmacotherapy.

The Norwegian RCT examined the influence of SC components on within-person

processes of change during CBT, administered in a residential program. Hoffart et al. (2015)

assigned PTSD patients (N = 67) to two groups receiving either a standard (n = 33) or a

modified (n = 34) form of prolonged exposure (PE) (Foa, Hembree, & Rothbaum, 2007),

which incorporates exposure to the traumatic memory through imagination (IE). In the

modified version of PE the imaginal exposure was adapted in order to foster SC by means of

imagery re-scripting (IR) (Stöfsel & Mooren, 2017). Treatment consisted of 10 weekly

individual sessions lasting 90 minutes and was delivered by experienced qualified therapists,

receiving ongoing supervision; treatment integrity was monitored and evaluated. The session


26

content for weeks 1, 2 and 10 was the same for both groups. PTSD symptoms and SC were

assessed weekly using self-report measures, and three days before the end of treatment

participants were asked to rate their experience. In their statistical analyses the researchers

disaggregated the within-person and the between-person components of change. Analysis of

the between-person effect of treatment revealed significant changes over the course of

treatment for five of the SCS subscales: self-kindness, mindfulness, self-judgment, isolation

and over-identification, no significant change was reported for common humanity; and there

were no significant differences between treatment groups. Analyses examining the within-

person effects of treatment found a significant association between higher than usual sores on

the SCS subscales of self-kindness, self-judgment, isolation and over-identification and lower

than usual levels of PTSD symptoms, as assessed three days later. Self-judgement was the

only SCS-subscale to show a positive cross-level effect. These analyses revealed no strong

reciprocal effects, i.e. there was no significant association between changes in PTSD

symptoms and subsequent SC levels.

This RCT was well-designed for investigating the potential of SC as an agent of

change in PTSD treatment as it incorporated specific assessment of within-person effects of

treatment. Matching the time and effort involved the both active treatments, treatment fidelity

assessment and supervision enhanced the internal validity of this study’s results. It could have

been strengthened further by using proportionate stratified random sampling, with the type of

trauma participants were exposed to as a variable.

Summary of outcomes

The included trials of interventions for SAD examined two MBPs: MBI-SAD

(Koszycki et al., 2016), which incorporates explicit SC-practices, and MBSR (Hjeltnes et al.,

2017; Jazaieri et al., 2012), which does not. MBSR and MBI-SAD were associated with

significant reductions in SA symptoms when participants were compared to untreated

controls. MBI-SAD was associated with a significant increase in SC. No significant

difference in SC was found between the active treatment groups in the study comparing

MBSR and AE (Jazaieri et al., 2012). Analyses of post therapy outcomes for MBI-SAD

revealed increases in SCS scores correlated negatively with scores of SA symptoms and

clinical global impression; session attendance correlated with engagement in formal practice,

and improvements in scores for SA symptoms, social adjustment and SC. The uncontrolled

trial of MBSR (Hjeltnes et al., 2017) reported a large effect size for SAD symptoms and

moderate to large effect sizes for the SCS-subscales. Correlation analyses of these outcomes

revealed significant positive associations between changes in SC and self-esteem; as well as


27

significant negative associations between changes in SA symptoms and both SC and self-

esteem. CFT (a MIP) was effective for three participants, probably effective for one and

effectiveness questionable for the remaining two participants (Boersma et al., 2015). Five

participants showed reliable improvement on SCS-scores, results for SA symptoms were

mixed.

Three studies investigated the effect of different MIPs incorporating self-compassion

practices on PTSD. The study examining LKM (Kearney et al., 2013) found this practice to

be safe and acceptable for veterans with PTSD. It reported large effect sizes for SC and PTSD

symptoms, both post treatment and at the 3 month follow-up; and evidence that enhanced SC

mediated reductions in PTSD symptoms. SC-workbook training (Held & Owens, 2015)

significantly increased levels of SC and reduced levels of trauma-related guilt, but no

significant changes were reported for PTSD symptoms. There were no significant differences

in treatment outcomes compared to participants in the active control group, who were

assigned to stress inoculation training. These findings indicated that a self-administered

workbook may constitute a feasible and acceptable format for delivering SC training to

disadvantaged populations. Comparing CMT coupled with CBT to CBT-only (Beaumont et

al., 2012) resulted in highly significant post-therapy reductions in symptoms of avoidant

behaviour, intrusive thoughts, hyper-arousal and anxiety for both groups, without finding

significant differences between the interventions. A significant increase in SC for both groups

was reported as well, with the CBT/CMT group developing significantly higher overall SCS-

scores.

Two studies focussed on processes of change in PTSD treatment. The first study (Valdez

& Lilly, 2016) found that SC may exert different effects on trauma-related anxiety and

affectivity across analytic and experiential trauma processing modes. In conditions of analytic

processing greater self-kindness correlated with less negative affectivity; mindfulness

correlated with less anxiety and negative affectivity, and greater positive affectivity; and

greater common humanity correlated with more anxiety. In experiential processing conditions

greater self-kindness correlated with more anxiety and positive affectivity; and greater

common humanity correlated with more anxiety. For the control group both greater

mindfulness and self-kindness correlated with greater less anxiety and negative affectivity.

The other study (Hoffart et al., 2015) explored within-person relationships between SC and

PTSD-symptoms, finding no differences in relations between treatment forms. Changes in

self-kindness, self-judgement, isolation and over-identification related to subsequent changes

in PTSD-symptoms. Participants with higher initial self-judgement showed a stronger within-


28

person relationship between self-judgement and subsequent PTSD symptoms. Within-person

variations in PTSD symptoms did not predict variations in SC-components.

Discussion

The aim of the present systematic review was to inform the development of

adaptations of MBPs and MIPs for SUDs. This was undertaken by examining treatment

outcomes and their relationship with self-compassion in trials of interventions for anxiety

disorders, and assessments of the feasibility and acceptability of these interventions.

The wide variety of interventions and population samples under examination, and the

methodological limitations of the included studies severely limits the generalisability of their

findings. This lack of comparability between the studies precludes drawing conclusions on the

effect of including explicit SC-practices in interventions, their effect on treatment outcomes,

and variations in effects between interventions aimed at PTSD and those for SAD. Therefore

the findings of the present review do not provide the type of evidence required to inform the

tailoring or adaptation of MBPs and MIPs in keeping with the problem formulation approach

advocated by Kocovski et al. (2009).

Nevertheless, taken as a whole the findings of the included studies included in this

review suggest that MBIs and MIPs may result in reductions in symptom severity and

increases in SC levels in participants with PTSD, SAD or related symptomatology. The

findings of included trials of MBPs and MIPs offer preliminary support for the predictive

utility of the SCS in MBIs for anxiety disorders suggested by Van Dam et al. (2010); as well

as additional support for the associations between increased levels of SC and reduced levels

of psychopathology and psychological health proposed by MacBeth and Gumley (2012) and

Neff, Rude and Kirkpatick (2007) respectively. Several included studies contribute to the

emerging body of mindfulness research by offering preliminary evidence for the feasibility

and acceptability of MBPs and MIPs that incorporate explicit SC-practices. No obvious

benefits were discernible for the inclusion of explicit SC-practices: the salutary effects of

increased SC were also observed in the trials of MBSR, where self-compassion is only

cultivated implicitly. Furthermore, these benefits were also observed in active control groups

that were exposed to therapeutic methods without an experiential component: AE and analytic

processing mode. Importantly, none of the included studies reported adverse events or side-

effects associated with explicit self-compassion practices.

Notwithstanding its limitations, the findings of this review may indicate a potential

utility of the SCS for clinicians working in SUD treatment. The reported correlations between

outcomes on the SCS-subscales and affectivity may have the potential to inform which


29

patients might benefit from LKM or compassion meditation, because positive and negative

affect are predicative of treatment outcomes for SUD (Marlatt & Donovan, 2008). The

reported associations between increased self-compassion and the other outcome measures

may be indicative of a similar potential. Processes and constructs such as avoidance, hyper-

arousal, isolation, self-criticism, guilt and shame are all associated with important risk factors

and determinants of relapse in the “Dynamic model of relapse” (Witkiewitz & Marlatt, 2009,

p. 414). Focused on situational dynamics, this model of relapse aims to inform clinicians

seeking to support their patients in identifying and preventing high-risk situations.

Consequently, clinicians utilising this model may find the SCS useful in discerning which

SUD-patients could benefit from the integration of LKM or compassion practice in their

treatment and relapse prevention plans.

Further research investigating of the role of SC in MBPs and MIPs is needed to

elucidate the role and effect of SC in the treatment of ADs and SU. Such research would

benefit from standardisation of the designs and measures used to investigate the efficacy of

MBPs and MIPs. And from clear definitions of the constructs and practices involved in

compassion meditation, mindfulness mediation and LKM as Shonin, Van Gordon, Compare,

Zangeneh and Griffith (2015) have argued. The difference between Gilbert’s definition of

compassion at the root of CFT and CMT (2010) and the one used by Neff (Neff, 2003a;

2003b) underpinning the SCS, indicates these issues around delineation also have a bearing

on the present review. Furthermore, as Curran and Bauer (2011) have pointed out, collecting

longitudinal data would offer advantages with regard to disaggregating between-person and

within-person effects. The reviewed findings reflect the focus on collecting the between

person data in assessing treatment outcomes noted by Hoffart et al. (2015) in one of the

included studies.

The present review has several serious limitations. The first limitation concerns the

literature search and selection of studies. These were conducted by a single reviewer,

introducing the possibility of bias through selection or omission. Limiting this search to two

electronic databases and studies published in English may add location and language biases.

Second, quality assessment and data extraction were also undertaken solely by the author,

which constitutes a vulnerability for assessment bias and errors. Finally, this review evaluates

the acceptability of therapeutic interventions examining only quantitative data, where

qualitative data have the potential to provide additional and detailed information about how

participants experience self-compassion practices.


30

Conclusions

The evidence presented in the current review offers preliminary support for the

efficacy of MBIs and MIPs in reducing symptom severity and increasing SC for patients with

PTSD, SAD or related symptomatology. It also suggests that integrating self-compassion

practices in the treatments for these patients may be feasible and acceptable across a wide

range of populations, treatment settings, and delivery methods. Additionally, the SCS may

have a potential use as an aid for clinicians seeking to discern which patients in SUD

treatment could benefit from self-compassion practices to facilitate therapeutic change.

However, given the lack of high-quality, large-scale trials, further research with

methodologically robust designs is needed to demonstrate the efficacy of increasing self-

compassion in the treatment of anxiety disorders and SUD. More research examining within-

person processes of change is needed to examine SCS’s potential to inform clinicians treating

patients with SUD.


31

References

Alcoholics Anonymous. (2001). Alcoholics Anonymous (4th ed.). New York: A.A. World

Services, Inc.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorder, text revision (DSM-IV-TR). Washington, D.C.: American Psychiatric

Association.

Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and

empirical review. Clinical Psychology: Science and Practice, 10(2), 125-143.

doi:10.1093/clipsy.bpg015

Baer, R. A. (2014). Introduction to the core practices and exercises. In R. A. Baer (Ed.),

Mindfulness-based treatment approaches: Clinicians's guide to evidence base and

applications (2nd ed., pp. 3-25). London: Academic Press.

Beaumont, E., Galpin, A., & Jenkins, P. (2012). 'Being kinder to myself': A prospective

comparative study, exploring post-trauma therapy outcome measures, for two groups of

clients, receiving either cognitive behaviour therapy or cognitive behaviour therapy and

compassionate mind training. Counselling Psychology Review, 27(1), 31-43.

Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., . . . Devins, G.

(2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science

and Practice, 11(3), 230-241. doi:10.1093/clipsy.bph077

Blacker, M., Meleo-Meyer, M., Kabat-Zinn, J., & Santorelli, S. (2009). Stress reduction clinic

mindfulness-based stress reduction (MBSR) curriculum guide. Unpublished manuscript.


32

Retrieved 26-04-2015, Retrieved from https://blackboard.bangor.ac.uk/bbcswebdav/pid-

1647087-dt-content-rid-3116323_1/xid-3116323_1

Bodhi, B. (Ed.). (2005). In the Buddha's words: An anthology of discourses from the Pali

canon. Somerville: Wisdom Publications.

Boersma, K., Håkanson, A., Salomonsson, E., & Johansson, I. (2015). Compassion focused

therapy to counteract shame, self-criticism and isolation. A replicated single case

experimental study for individuals with social anxiety. Journal of Contemporary

Psychotherapy, 45(2), 89-98. doi:10.1007/s10879-014-9286-8

Bowen, S., Chawla, N., & Marlatt, G. A. (2011). Mindfulness-based relapse prevention for

addictive behaviours: A clinician's guide. New York: The Guilford Press.

Brach, T. (2003). Het leven liefhebben door acceptatie [Radical Acceptance]. Utrecht:

Kosmos.

Cannon, W. B. (1929). Bodily changes in pain, hunger, fear and rage. Oxford: Appleton.

Centre for Reviews and Dissemination. (2009). Systematic reviews: CRD's guidance for

undertaking reviews in health care. York: University of York. Retrieved from

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUK

Ewjtr8HM3cbdAhWH16QKHZAeBq4QFjAAegQIARAC&url=https%3A%2F%2Fww

w.york.ac.uk%2Fmedia%2Fcrd%2FSystematic_Reviews.pdf&usg=AOvVaw3TR0y4OG

UfJUrTMRdyWB4q

Conger, J. J. (1956). Reinforcement theory and the dynamics of alcoholism. Quarterly

Journal of Studies on Alcohol, 17, 296-305.

https://blackboard.bangor.ac.uk/bbcswebdav/pid-1647087-dt-content-rid-3116323_1/xid-3116323_1

https://blackboard.bangor.ac.uk/bbcswebdav/pid-1647087-dt-content-rid-3116323_1/xid-3116323_1

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwjtr8HM3cbdAhWH16QKHZAeBq4QFjAAegQIARAC&url=https%3A%2F%2Fwww.york.ac.uk%2Fmedia%2Fcrd%2FSystematic_Reviews.pdf&usg=AOvVaw3TR0y4OGUfJUrTMRdyWB4q





33

Crane, R. S., Brewer, J., Feldman, C., Kabat-Zinn, J., Santorelli, S., Williams, J. M. G., &

Kuyken, W. (2016). What defines mindfulness-based programs? The warp and the weft.

Psychological Medicine, 47(6), 990-999. doi:10.1017/S0033291716003317

Critical Appraisal Skills Programme. (2018). CASP randomised controlled trial checklist.

Retrieved from http://casp-uk.net/wp-content/uploads/2018/01/CASP-Systematic-

Review-Checklist_2018.pdf

Curran, P. J., & Bauer, D. J. (2011). The disaggregation of within-person and between-person

effects in longitudinal models of change. Annual Review of Psychology, 62(1), 583-619.

doi:10.1146/annurev.psych.093008.100356

Daley, D. C., & Moss, H. B. (2003). Anxiety disorders and chemical dependency. Dual

disorders (3rd ed., ). Center City, Minnesota: Hazelden.

Didonna, F. (2009). Introduction: Where new and old paths to dealing with suffering meet. In

F. Didonna (Ed.), Clinical handbook of mindfulness (pp. 1-14). New York: Springer

Science+Business Media.

Feldman, C., & Kuyken, W. (2011). Compassion in the landscape of suffering. Contemporary

Buddhism, 12(1), 143-155.

Fisher, L. D., Dixon, D. O., Herson, J., Frankowski, R. K., Hearron, M. S., & Peace, K. E.

(1990). Intention to treat in clinical trials. In K. E. Peace (Ed.), Statistical issues in drug

research and development. (pp. 331–50). New York: Marcel Dekker.

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for

PTSD: Emotional processing of traumatic experiences. New York: Oxford University

Press.

http://casp-uk.net/wp-content/uploads/2018/01/CASP-Systematic-Review-Checklist_2018.pdf

http://casp-uk.net/wp-content/uploads/2018/01/CASP-Systematic-Review-Checklist_2018.pdf


34

Garland, E. (2013). Mindfulness-oriented recovery enhancement for addiction, stress and

pain. Washington, DC: NASW Press.

Gilbert, P. (2010). Compassion focused therapy. Hove: Routledge.

Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame

and self‐criticism: Overview and pilot study of a group therapy approach. Clinical

Psychology & Psychotherapy, 13(6), 353-379. doi:10.1002/cpp.507

Goldin, P. R., Ziv, M., Jazaieri, H., Werner, K., Kraemer, H., Heimberg, R. G., & Gross, J. J.

(2012). Cognitive reappraisal self-efficacy mediates the effects of individual cognitive-

behavioral therapy for social anxiety disorder. Journal of Consulting and Clinical

Psychology, 80(6), 1034-1040. doi:10.1037/a0028555

Greeson, J., & Brantley, J. (2009). Mindfulness and anxiety disorders: Developing a wise

relationship with the inner experience of fear. In F. Didonna (Ed.), Clinical handbook of

mindfulness (pp. 171-188). New York, NY: Springer New York. doi:10.1007/978-0-387-

09593-6_11

Harris, K. M., & Edlund, M. J. (2005). Use of mental health care and substance abuse

treatment among adults with co-occurring disorders. Psychiatric Services, 56(8), 954-

959. doi:10.1176/appi.ps.56.8.954

Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy.

New York: Guilford Press.

Hayes, S. C. (2016). Acceptance and commitment therapy, relational frame theory, and the

third wave of behavioral and cognitive therapies – republished article

doi://doi.org/10.1016/j.beth.2016.11.006


35

Held, P., & Owens, G. P. (2015). Effects of Self‐Compassion workbook training on Trauma‐

Related guilt in a sample of homeless veterans: A pilot study. Journal of Clinical

Psychology, 71(6), 513-526. doi:10.1002/jclp.22170

Henderson, L., & Gilbert, P. (2011). The compassionate-mind guide to building social

confidence: Using compassion-focused therapy to overcome shyness and social anxiety.

Oakland: New Harbinger Publications.

Higgins, J. P. T., & Green, S. (2011). Cochrane handbook for systematic reviews of

interventions. Retrieved from http://www.handbook.cochrane.org

Hippocrates. (1886). The genuine works of hippocrates (vol. 2). New York: Wood W.

Hjeltnes, A., Molde, H., Schanche, E., Vøllestad, J., Lillebostad Svendsen, J., Moltu, C., &

Binder, P. (2017). An open trial of mindfulness‐based stress reduction for young adults

with social anxiety disorder. Scandinavian Journal of Psychology, 58(1), 80-90.

doi:10.1111/sjop.12342

Hoffart, A., Øktedalen, T., & Langkaas, T. F. (2015). Self-compassion influences PTSD

symptoms in the process of change in trauma-focused cognitive-behavioral therapies: A

study of within-person processes. Frontiers in Psychology, 6

doi:10.3389/fpsyg.2015.01273

Hölzel, B. K., Lazar, S. W., Gard, T., Schuman-Oliver, Z., Vago, D. R., & Ott, U. (2011).

How does mindfulness meditation work? proposing mechanisms of action from a

conceptual and neural perspective. Perspectives on Psychological Science, 6(537)

doi:10.1177/174569161149671

http://www.handbook.cochrane.org/


36

Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining

meaningful change in psychotherapy research. Journal of Consulting and Clinical

Psychology, 59(1), 12-19. doi:10.1037//0022-006X.59.1.12

Jazaieri, H., Goldin, P. R., Werner, K., Ziv, M., & Gross, J. J. (2012). A randomized trial of

MBSR versus aerobic exercise for social anxiety disorder. Journal of Clinical

Psychology, 68(7), 715-731. doi:10.1002/jclp.21863

Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future.

Clinical Psychology: Science and Practice, 10(2), 144-156. doi:10.1093/clipsy.bpg016

Kabat-Zinn, J. (2005). Full catastrophe living: How to cope with stress, pain and illness using

mindfulness meditation (15th ed.). New York: Bantam Dell.

Kahl, K. G., Winter, L., & Schweiger, U. (2012). The third wave of cognitive behavioural

therapies: What is new and what is effective? Current Opinion in Psychiatry, 25(6), 522-

528. doi:10.1097/YCO.0b013e328358e531

Kearney, D. J., Malte, C. A., McManus, C., Martinez, M. E., Felleman, B., & Simpson, T. L.

(2013). Loving‐Kindness meditation for posttraumatic stress disorder: A pilot study.

Journal of Traumatic Stress, 26(4), 426-434. doi:10.1002/jts.21832

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005).

Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national

comorbidity survey replication. Archives of General Psychiatry, 62(6), 593-602.

doi:10.1001/archpsyc.62.6.593


37

Kocovski, N. L., Segal, Z. V., & Battista, S. R. (2009). Mindfulness and psychopathology:

Problem formulation. In F. Didonna (Ed.), Clinical handbook of mindfulness (pp. 85-98).

New York, NY: Springer New York. doi:10.1007/978-0-387-09593-6_6

Koster, F. (2012). Bevrijdend inzicht: Een kennismaking met boeddhistische psychologie,

mindfulness en inzichtmeditiatie

[Liberating insight: An introduction to Buddhist psychology, mindfulness and insight

meditation] (6th ed.). Rotterdam: Asoka.

Koszycki, D., Thake, J., Mavounza, C., Daoust, J., Taljaard, M., & Bradwejn, J. (2016).

Preliminary investigation of a mindfulness-based intervention for social anxiety disorder

that integrates compassion meditation and mindful exposure. The Journal of Alternative

and Complementary Medicine, 22(5), 363-374. doi:10.1089/acm.2015.0108

Kushner, M. G., Sher, K. J., & Beitman, B. D. (1990). The relation between alcohol problems

and the anxiety disorders. The American Journal of Psychiatry, 147(6), 685-95.

Retrieved from https://search.proquest.com/docview/220477308?accountid=14874

Kuyken, W., & Evans, A. C. (2014). Mindfulness-based relapse cognitive therapy for

recurrent depression. In A. E. Baer (Ed.), Mindfulness-based treatment approaches:

Clinicians's guide to evidence base and applications (2nd ed., pp. 29-60). London:

Academic Press.

Kuyken, W., Watkins, E., Holden, E., White, K., Taylor, R. S., Byford, S., . . . Dalgleish, T.

(2010). How does mindfulness-based cognitive therapy work? Behaviour Research and

Therapy, 48(11), 1105-1112. doi://doi.org/10.1016/j.brat.2010.08.003

https://search.proquest.com/docview/220477308?accountid=14874


38

Leaviss, J., & Uttley, L. (2015). Psychotherapeutic benefits of compassion-focused therapy:

An early systematic review. Psychological Medicine, 45(5), 927-945.

doi:10.1017/S0033291714002141

Li, W., Howard, M. O., Garland, E. L., McGovern, P., & Lazar, M. (2017). Mindfulness

treatment for substance misuse: A systematic review and meta-analysis. Journal of

Substance Abuse Treatment, 75, 62-96.

Lindahl, J. R., Fisher, N. E., Cooper, D. J., Rosen, R. K., & Britton, W. B. (2017). The

varieties of contemplative experience: A mixed-methods study of meditation-related

challenges in western buddhists. PLoS One, 12(5), e0176239.

doi:10.1371/journal.pone.0176239

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder.

New York: Guilford Press.

Ma, H. (2006). An alternative method for quantitative synthesis of single-subject researches.

Behavior Modification, 30(5), 598-617. doi:10.1177/0145445504272974

MacBeth, A., & Gumley, A. (2012). Exploring compassion: A meta-analysis of the

association between self-compassion and psychopathology. Clinical Psychology Review,

32(6), 545-552. doi:10.1016/j.cpr.2012.06.003

Marlatt, G. A., & Donovan, D. M. (Eds.). (2008). Relapse prevention: Maintenance strategies

in the treatment of addictive behaviors (2nd ed.). New York: The Guilford Press.

McGovern, M. P., Xie, H., Segal, S. R., Siembab, L., & Drake, R. E. (2006). Addiction

treatment services and co-occurring disorders: Prevalence estimates, treatment practices,


39

and barriers. Journal of Substance Abuse Treatment, 31(3), 267-275.

doi:10.1016/j.jsat.2006.05.003

Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for

systematic reviews and meta-analyses: The PRISMA statement. PLOS Medicine, 6(7),

e1000097. Retrieved from https://doi.org/10.1371/journal.pmed.1000097

Moos, R. H. (2009). Addictive disorders in context: Principles and puzzles of effective

treatment and recovery. In G. A. Marlatt, & K. Witkiewitz (Eds.), Addictive behaviors:

New readings on etiology, prevention, and treatment (pp. 537-558) American

Psychological Association. doi:10.1037/11855-021

Narcotics Anonymous. (2008). Narcotics Anonymous (6th ed.). Chatsworth: NA World

Services, Inc.

National Institute on Drug Abuse. (2018). Principles of drug treatment: A research-based

guide (3rd ed.). Bethesda MD, United States: National Institute on Drug Abuse.

Retrieved from https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/675-principles-of-

drug-addiction-treatment-a-research-based-guide-third-edition.pdf

Neff, K. (2003a). The development and validation of a scale to measure self-compassion. Self

and Identity, 2(3), 223-250. doi:10.1080/15298860309027

Neff, K. (2003b). Self-compassion: An alternative conceptualization of a healthy attitude

toward oneself. Self and Identity, 2(2), 85-101. doi:10.1080/15298860309032

Neff, K. (2016). The self-compassion scale is a valid and theoretically coherent measure of

self-compassion. Mindfulness, 7(1), 264-274. doi:10.1007/s12671-015-0479-3

https://doi.org/10.1371/journal.pmed.1000097

https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/675-principles-of-drug-addiction-treatment-a-research-based-guide-third-edition.pdf

https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/675-principles-of-drug-addiction-treatment-a-research-based-guide-third-edition.pdf


40

Neff, K. (2018). Self-compassion publications. Retrieved from http://self-compassion.org/the-

research/

Neff, K., Rude, S., & Kirkpatrick, K. (2007). An examination of self-compassion in relation

to positive psychological functioning and personality traits. Journal of Research in

Personality, 41(4), 908-916. doi://doi.org/10.1016/j.jrp.2006.08.002

Öst, L. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and

meta-analysis. Behaviour Research and Therapy, 46(3), 296-321.

doi://doi.org/10.1016/j.brat.2007.12.005

Penberthy, J. K., Konig, A., Gioia, C. J., Rodríguez, V. M., Starr, J. A., Meese, W., . . .

Natanya, E. (2015). Mindfulness-based relapse prevention: History, mechanisms of

action, and effects. Mindfulness, 6(2), 151-158.

Raes, F., Pommier, E., Neff, K. D., & Van Gucht, D. (2011). Construction and factorial

validation of a short form of the Self‐Compassion scale. Clinical Psychology &

Psychotherapy, 18(3), 250-255. doi:10.1002/cpp.702

Rodebaugh, T. L., Holaway, R. M., & Heimberg, R. G. (2004). The treatment of social

anxiety disorder. Clinical Psychology Review, 24(7), 883-908.

doi:10.1016/j.cpr.2004.07.007

Salzberg, S. (2011). Liefdevolle vriendelijkheid: Een ander perspectief op geluk

[Lovingkindness] (K. Merkus Trans.). (5th ed.). Nieuwerkerk a/d IJssel: Ashoka.

SAMSHA. (2005). Substance abuse treatment for persons with co-occurring disorders.

Rockville, MD: U.S. Dept. of Health and Human Services, Substance Abuse and Mental

http://self-compassion.org/the-research/

http://self-compassion.org/the-research/


41

Health Services Administration, Center for Substance Abuse Treatment. Retrieved from

http://purl.access.gpo.gov/GPO/LPS72393

Schmidt, N. B., Richey, J. A., Zvolensky, M. J., & Maner, J. K. (2007). Exploring human

freeze responses to a threat stressor. Journal of Behavior Therapy and Experimental

Psychiatry, 39(3), 292-304. doi:10.1016/j.jbtep.2007.08.002

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness en cognitieve therapie

bij depressie [Mindfulness-based cognitive therapy for depression: Second edition] (R.

Van de Weijer, S. Wagenaar & J. Langeveld Trans.). (2nd ed.). Amsterdam: Uitgeverij

Nieuwezijds.

Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of

mindfulness. Journal of Clinical Psychology, 63(3) doi:10.1002/jclp.20237

Shonin, E., Van Gordon, W., Compare, A., Zangeneh, M., & Griffiths, M. (2015). Buddhist-

derived loving-kindness and compassion meditation for the treatment of

psychopathology: A systematic review. Mindfulness, 6(5), 1161-1180.

doi:10.1007/s12671-014-0368-1

Stöfsel, M., & Mooren, T. (2017). Trauma en persoonlijkheidsproblematiek [Trauma and

personality functioning]. Houten: Bohn, Staffleu en van Loghum.

United Nations Office on Drugs and Crime. (2017). World drug report 2017 - executive

summary - conclusions and policy implications. New York: United Nations.

doi:10.18356/66312961-en Retrieved from

https://www.unodc.org/wdr2017/field/Booklet_1_EXSUM.pdf

http://purl.access.gpo.gov/GPO/LPS72393

https://www.unodc.org/wdr2017/field/Booklet_1_EXSUM.pdf


42

Valdez, C., & Lilly, M. (2016). Self-compassion and trauma processing outcomes among

victims of violence. Mindfulness, 7(2), 329-339. doi:10.1007/s12671-015-0442-3

Van Dam, N. T., Sheppard, S. C., Forsyth, J. P., & Earleywine, M. (2010). Self-compassion is

a better predictor than mindfulness of symptom severity and quality of life in mixed

anxiety and depression. Journal of Anxiety Disorders, 25(1), 123-130.

doi:10.1016/j.janxdis.2010.08.011

Van den Bree, M., Bonner, A., Taylor, P. J., & Shelton, K. H. (2009). Risk factors for

homelessness: Evidence from a population-based study. Psychiatric Services, 60(4), 465-

472. doi:10.1176/ps.2009.60.4.465

Walsh, R., & Roche, L. (1979). Precipitation of acute psychotic episodes by intensive

meditation in individuals with a history of schizophrenia. The American Journal of

Psychiatry, 136(8), 1085-1086.

Witkiewitz, K., Bowen, S., Harrop, E. N., Douglas, H., Enkema, M., & Sedgwick, C. (2014).

Mindfulness-based treatment to prevent addictive behavior relapse: Theoretical models

and hypothesized mechanisms of change. Substance use & Misuse, 49(5), 513-524.

doi:10.3109/10826084.2014.891845

Witkiewitz, K., & Marlatt, G. A. (2009). Relapse prevention for alcohol and drug problems:

That was Zen, this is Tao. In G. A. Marlatt, & K. Witkiewitz (Eds.), Addictive

behaviours: New readings on etiology, prevention, and treatment (pp. 403-427).

Washington, D.C.: American Psychological Association.


43

World Health Organization. (2014). Global status report

on alcohol and health. Geneva, Switserland: WHO. Retrieved from

http://www.who.int/iris/bitstream/10665/112736/1/9789240692763_eng.pdf

Young, R. D., Oei, T. P., & Knight, R. G. (2010). The tension reduction hypothesis revisited:

An alcohol expectancy perspective. British Journal of Addiction, 85(1), 31-40.

doi:10.1111/j.1360-0443.1990.tb00621.x

http://www.who.int/iris/bitstream/10665/112736/1/9789240692763_eng.pdf


44

APPENDIX A

Tables

Table 1

Primary Anxiety Disorders, Clinical Descriptions, and Lifetime Prevalence (Greeson &

Brantley, 2009, p. 173)

Diagnostic Category Clinical Description Lifetime Prevalence*

Generalised anxiety disorder Persistent, pervasive worry

that is difficult to control

5%

Obsessive-compulsive

disorder

Obsessive thinking about

possible threats to safety and

compulsive ritualistic

behaviours to allay fear

2.5%

Panic disorder Southern, overwhelming,

intense fear of something

going wrong

1.0-3.5%

Post-traumatic stress disorder Intrusive thoughts,

hyperarousal, and re-

experience of past trauma

8%

Social anxiety disorder Fear of negative social

evaluation

Up to 13%

Specific phobia Fear of a specific object or

situation

7-11%

* Obtained from DSM-IV-TR, American (Young et al., 2010) Psychiatric Association (2000)


45

Table 2

Summary description of study designs, populations, interventions and main outcomes

Study N Design Population Intervention Control

group

Measures Main Outcomes

Held & Owens

2015

47 RCT Homeless

veterans in

transitional

housing

Self-

compassion

workbook

Stress

inoculation

workbook

THS, SCS,

TRGI, PCL-

S

Increased levels of self-compassion and

reduced levels of trauma-related guilt for

both groups. No significant differences

found in PTSD severity.

Hoffart et al.

2015

65 RCT PTSD patients

in residential

care

Prolonged

exposure

modified to

include

imagery re-

scripting

Standard

prolonged

exposure

PSS-SR, SCS 5 of the SCS-subscales demonstrated

change independent of therapy form: self-

kindness, mindfulness, self-judgement,

isolation and over-identification; only

common humanity did not. These changes

had a within-person effect on PTSD

symptoms: patients with higher initial self-

judgement showed a stronger within-person

relationship between self-judgement and

subsequent PTSD symptoms. Within-person

variations in PTSD symptoms did not

predict variations in self-compassion

components.

Jazaieri et al.

2012

56 RCT Patients with

principal

diagnosis of

SAD

MBSR vs.

Aerobic

Exercise

Non-

randomised

healthy

controls and

untreated

participants

with SAD

KIMS,

LSAS-SR,

SIAS-S,

BDI-II, PSS-

4, RSE,

SLWLS,

SCS, ULS-8

Comparable significant changes in both

treatment groups, both post treatment and at

3 month follow-up: reductions in social

anxiety and increases in subjective well-

being.


46

Table 2 (continued)


group


Koszycki et al.

2016

39 RCT Patients

with SAD

MBI-SAD Waitlist LSAS, SPIN,

GCI-S, BDI-

II, SAS-SR,

SCS-SF,

FFMQ

MBI-SAD feasible and acceptable. Greater

improvement in social anxiety symptom

severity, and social adjustment for MBI-

SAD group. Enhanced self-compassion

compared to WL. Gains maintained at 3-

month follow-up.

Valdez & Lily

2016

63 RCT Female

trauma

survivors

Negative

affect vs.

positive affect

processing

induction

Control

with

neutral

processing

induction

TLEQ, PCL-

C, SCS, BAI,

PANAS-X

At baseline less PTSD symptoms correlates

with greater over-all self-compassion. Post-

treatment greater the mindfulness and self-

kindness SCS-subscales correlated with

greater less anxiety and negativity in C;

greater self-kindness correlated with less

negative affectivity and mindfulness

correlated with less anxiety and negative

affectivity, and greater positive affectivity in

NA; and greater common humanity

correlated with more anxiety, and greater

self-kindness correlated with more anxiety

and positive affectivity in PA.

Boersma et al.

2015

6 Replicated

single case

design

University

students

suffering

from SA

CFT None SPSQ, SIAS,

SCS,

treatment

evaluation,

diary ratings

of shame,

self-criticism

and self-

compassion

CFT effective for three participants,

probably effective for one and effectiveness

questionable for two participants. Five

participants showed reliable improvement

on SCS-scores, mixed results for SA

symptoms. Half of the participants showed

clinically significant improvement on SPSQ

outcomes. Half of participants “very

satisfied” with treatment, the other half


47

Table 2 (continued)


group


“quite satisfied”; half of participants found

they had improved “a lot”, the other half

“somewhat”.

Hjeltnes et al.

2017

53 Longitudinal

follow-up

study

University

students with

SAD or social

anxiety

problems

MBSR None SPS, SCL-90-

R, FFMQ,

SCS, RSE

Large to moderate effect sizes for SAD

symptoms and global psychological distress.

Moderate to large effects for self-

compassion. Significant positive

associations between changes in self-

compassion and self-esteem; significant

negative association between changes in SA

symptoms and both self-compassion and

self-esteem. Clinically significant or reliable

change for two thirds of participants.

Kearney et al.

2013

48 Longitudinal

follow-up

study

Veterans with

PTSD

LKM None PSS-I, SCS,

PROMIS,

CLS, FFMQ

LKM highly acceptable for veterans: 74%

completed treatment. Larger effect sizes for

increased self-compassion, medium to large

effect size for increase in mindfulness post-

treatment and at follow-up. Large effect size

for reduction in PTSD symptom and

medium effect size for depression found at

3-month follow-up. Evidence for enhanced

self-compassion as mediator of reductions in

both PTSD and depression symptoms.


48

Table 2 (continued)


group


Beaumont et

al. 2012

32 Comparative

interventional

study

Convenience

sample,

referred for

CBT after

traumatic

incident

CBT

combined

with CMT

CBT HADS, IES,

SCS-SF

Highly significant reduction post therapy in

symptoms of avoidant behaviour, intrusive

thoughts, hyper-arousal symptoms, anxiety

and depression for both groups; no

significant difference between groups.

Highly significant increase in self-

compassion for both groups; combined

CBT/CMT group reported significantly

higher overall SCS-scores.

Note: Design: RCT = Randomised Controlled Trial.

Population: PTSD = Post-Traumatic Stress Disorder; SAD = Social Anxiety Disorder,

Intervention: CBT = Cognitive Behavioural Therapy; CMT = Compassionate Mind Training; CFT = Compassion Focussed Therapy; MBSR =

Mindfulness-Based Stress Reduction; LKM = Loving-Kindness Meditation; MBI-SAD = Mindfulness-Based Intervention for Social Anxiety

Disorder.

Measures: HADS = Hospital Anxiety and Depression Scale; Impact of Events Scale; SCS-SF = Self-Compassion Scale - Short Form; SPSQ =

Social Phobia Screening Questionnaire; SIAS = Social Interaction Anxiety Scale; SCS = Self-Compassion Scale; THS = Trauma History Screen;

TRGI = Trauma-Related Guilt Inventory; PCL-S = PTSD Checklist-Specific Stressor Version; SPS = Social Phobia Scale;

SCL-90-R = Symptom Checklist 90 Revised; FFMQ = Five Facet Mindfulness Questionnaire; RSE = Rosenberg Self Esteem Scale; PSS-R =

PTSD Symptom Scale - Self-Report; KIMS = Kentucky Inventory of Mindfulness Scale; LSAS-SR = Liebowitz Social Anxiety Scale - Self-

Report; SIAS-S = Social Interaction Anxiety Scale Straightforward Scale; BDI-II = Beck Depression Inventory - II; PSS-4 = Perceived Stress

Scale; SWLS = Satisfaction with Life Scale; ULS-8 = UCLA-8 Loneliness Scale; PSS-I = PTSD Symptom Scale Interview; PROMIS = Patient-

Reported Outcomes Measurement Information System; CLS = Compassionate Love Scale; SPIN = Social Phobia Inventory; GCI-S = Clinical

Global Impression–Severity Scale; SAS-SR = Social Adjustment Self-Report Scale; TLEQ = Traumatic Life Events Questionnaire; PCL-C =

PTSD Checklist-`civilian Version; BAI = Beck Anxiety Inventory; PANAS-X = Positive and Negative Affect Schedule – Expanded Form.

Main Outcomes: SA = Social Anxiety; SAD = Social Anxiety Disorder; AE = Aerobic Exercise; WL = Waitlist; C = Control; NA = Negative

Affect processing induction; PA = Positive Affect processing induction.


49

Table 3

Summary description of disorders, populations, treatment and (self-)compassion components incorporated in treatments under examination

Study Disorder /

symptomatology

Clinical / non-

clinical

population

Intervention(s)

and control

group

Therapist

details

Duration of

intervention

Treatment

adherence

monitoring

and

supervision

(Self-)compassion

or LKM component

Held & Owens

2015

PTSD / Trauma-

related guilt

Non-clinical;

homeless

veterans living

in transitional

housing facility

Self-

compassion

workbook;

Stress-

inoculation

workbook

NA (self-

administered

via workbook,

introductory

group session)

4 weeks;

participants

requested to

read workbook

sections and

practice

exercises for

min. of 5-15

min. daily

Use of

workbooks

verified

Compassionate

awareness of

present moment

experience;

compassionate

responding to own

experience; writing

compassionate letter

to self

Hoffart et al.

2015

PTSD Clinical in

residential care

Prolonged

exposure

modified to

include

imagery re-

scripting

(individual)

Certified,

experienced

(> 10 years)

CBT therapists

10 weekly 90

min. sessions

Treatment

adherence

monitored;

individual

and group

supervision

Imagined

interaction of

‘Current Self ‘

providing care and

emotional support in

various ways for

‘Traumatised Self’

Jazaieri et al.

2012

SAD Clinical

(healthy, non-

randomised

controls

included in

analyses)

MBSR vs. AE

MBSR:

experienced

teachers;

training NS

AE instructors:

NS

MBSR: 8

weekly 2 ½ to 3

hour group

sessions; one all

day practice

session; formal

and informal

homework

practice

NS No explicit (self-)

compassion or LKM

practice included


50

Table 3 continued

Study Disorder /

symptomatology

Clinical / non-

clinical

population

Intervention(s)

and control

group

Therapist

details

Duration of

intervention

Treatment

adherence

monitoring

and

supervision

(Self-)compassion

or LKM component

AE: 1 weekly

group session,

plus minimum

of 2 individual

sessions weekly

Koszycki et al.

2016

SAD Clinical MBI-SAD Registered

psychologist

with expertise

in treating

DAD, formal

training in

MBIs and a

personal

mindfulness

practice.

12 weekly 2-

hour group

sessions

NS LKM; self-

compassion

meditations as

described by Brach

(2003); psycho-

education around

self-compassion and

its relation to both

SAD and general

well-being

Valdez & Lily

2016

Trauma-

survivors /

PTSD

Non-clinical; all

female sample

“Analytic” vs.

“Experimental”

processing

induction vs.

“neutral”

control

induction

Undergraduate

research

assistant;

trauma specific

pervasive

thinking

interview

administered

by clinical

psychologist

1.5 hour

individual

session


compassion or LKM

practice included


51

Table 3 continued

Study Disorder /

symptomatology

Clinical / non-

clinical

population

Intervention(s)

and control

group

Therapist

details

Duration of

intervention

Treatment

adherence

monitoring

and

supervision

(Self-)compassion

or LKM component

Boersma et al.

2014

SA / SAD Non-clinical;

screened for

fulfilment of

DSM-IV SA

criteria

Individual CFT Psychology

students

finalising

clinical training

8 weekly 1-hour

sessions

Adherence

of

manualised

intervention

NS; weekly

supervision.

“Safe Place”

imagery exercise;

generation

compassionate

thoughts exercise;

experiencing

compassion from

others exercise;

feeling compassion

for others exercise;

writing


to self

Hjeltnes et al.

2017

SAD Non-clinical MBSR Clinical

psychologist;

formal MBSR

teacher training

specified for 1

of 6 therapists

8 weekly 2 ½-3

hour group

sessions; all day

practice session;

formal and

informal

homework

practice


compassion or LKM

practice included

Kearney et al.

2013

PTSD Clinical LKM Experienced

mediation

teachers;

training NS

12 weekly 90

minute group

sessions

NS LKM


52

Table 3 continued

Study Disorder /

symptomatology

Clinical / non-

clinical

population

Intervention(s)

and control

group

Therapist

details

Duration of

intervention

Treatment

adherence

monitoring

and

supervision

(Self-)compassion

or LKM component

Beaumont et

al. 2012

PTSD / Trauma

related

symptoms

Non-clinical;

experienced

traumatic

incident

Individual

CBT coupled

with CMT

Single, CBT-

accredited

therapist

Up to 12

sessions;

duration NS

NS Challenging of

“internal bully”

using imagery;


writing; and

grounding work

(using memory

triggers associated

with safety and

relaxation)

Note: Disorder / Symptomatology: PTSD = Post-Traumatic Stress Disorder; SA = Social Anxiety; SAD = Social Anxiety Disorder

Clinical / non-clinical population: DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, America Psychiatric Association.

Intervention and control group: CBT = Cognitive Behavioural Therapy; CMT = Compassionate Mind Training; CFT = Compassion Focussed

Therapy; MBSR = Mindfulness-Based Stress Reduction; AE = Aerobic Exercise; LKM = Loving-Kindness Meditation; MBI-SAD =

Mindfulness-Based Intervention for Social Anxiety Disorder.

Therapist details: NS = not specified.


53

Table 4

Summary of outcomes of quality assessment with CRD-tool, denoting quality criteria and related potential for confounding and bias.

Randomisation

(allocation bias) Baseline

comparability

(confounding)

Eligibility

(selection bias) Blinding

(detection bias) Withdrawals

(attrition bias) Outcomes

(reporting

bias)

Study

Tru

ly

ran

do

m

All

oca

tio

n

con

ceal

men

t

Nu

mb

er

stat

ed

Pre

sen

ted

Ach

iev

ed

Eli

gib

ilit

y

crit

eria

spec

ifie

d

Co

-

inte

rven

tio

ns

iden

tifi

ed

Ass

esso

rs

Ad

min

istr

ati

on

Par

tici

pan

ts

Pro

ced

ure

asse

ssed

80

% i

n f

inal

anal

ysi

s

Rea

son

s

stat

ed

Un

exp

ecte

d

dro

p-o

uts

Inte

nti

on

to

trea

t

Oth

er

ou

tco

mes

Held &

Owens

2015

NS NA

Hoffart et

al. 2015

Jazaieri et

al. 2012

Koszycki

et al. 2016

NA

Valdez &

Lily 2016

Hoffart et

al. 2015

Boersma

et al. 2015

NA NA NA NA NA NA NA NA NA

Hjeltnes et

al. 2017

NA NA NA NA NA NA NA NA NA NS NS

Kearney et

al. 2013

NA NA NA NA NA NA NS NA NA

Beaumont

et al. 2012

NA NA NA NS

Note: = yes (item adequately addressed); = no (item not adequately addressed); = partially (item partially addressed; NS = not stated; NA = not applicable


54

APPENDIX B

Interventions for anxiety disorders and Self-Compassion Scale screening and selection tool

Date:

Author name(s): Year:

Title: Journal:

-----------------------------------------------------------------------------------------------------------------

Patient population

Include Exclude

Adults diagnosed with an anxiety disorder Studies including children or minors

No AD diagnosis or symptoms

Intervention(s)

Include Exclude

Conducted in clinical or outpatient setting No experiential treatment component

Not peer reviewed

Outcomes

Must include Exclude

Self-Compassion Scale SCS not used

Anxiety symptom severity Anxiety symptoms not assessed

May include

Feasibility Quality of life

Treatment acceptability Treatment adherence

Study design

Include Exclude

Examines AD intervention Not examining AD

Systematic review or meta-analysis

Overall decision INCLUDED EXCLUDED

NOTES


55

APPENDIX C

CRD informed research study quality assessment tool

Author name/Study ID:

Quality item:

Randomisation (check for allocation bias)

Was the method used to assign participants to the treatment groups truly random?

Was the allocation of treatment concealed?

Was the number of participants randomised stated?

Comparability (check for confounding)

Where details of baseline comparability presented?

Was baseline comparability achieved?

Blinding (check for detection bias)

Were outcome assessors blinded to treatment allocation?

Were individuals who administered the intervention blinded to treatment allocation?

Were participants blinded to treatment allocation?

Was the success of the blinding procedures assist?

Withdrawals (check for attrition bias)

Were > 80% of participants randomised included in the final analysis?

Were reasons for participant withdrawals stated?

Was there any unexpected dropouts in either group?

Was an intention to treat analysis included?

Outcomes (check for outcome reporting bias)

is there evidence that more outcomes were measured than were reported?


56

APPENDIX D

CASP RCT CHECKLIST

CASP Checklist: 11 questions to help you make sense of a Randomised

Controlled Trial

How to use this appraisal tool: Three broad issues need to be considered when appraising a trial:

Are the results of the study valid? (Section A)

What are the results? (Section B)

Will the results help locally? (Section C)

The 11 questions on the following pages are designed to help you think about these issues systematically. The

first three questions are screening questions and can be answered

quickly. If the answer to both is “yes”, it is worth proceeding with the remaining questions. There is

some degree of overlap between the questions, you are asked to record a “yes”, “no” or “can’t tell”

to most of the questions. A number of italicised prompts are given after

each question. These are designed to remind you why the question is important. Record your reasons

for your answers in the spaces provided.

About: These checklists were designed to be used as educational pedagogic tools, as part of a workshop

setting, therefore we do not suggest a scoring system. The core CASP checklists (randomised controlled

trial & systematic review) were based on JAMA 'Users’ guides to the medical literature 1994 (adapted

from Guyatt GH, Sackett DL, and Cook DJ), and piloted with health care practitioners.

For each new checklist, a group of experts were assembled to develop and pilot the checklist and the

workshop format with which it would be used. Over the years overall adjustments have been made to

the format, but a recent survey of checklist users reiterated that the basic format continues to be

useful and appropriate.

Referencing: we recommend using the Harvard style citation, i.e.: Critical Appraisal Skills Programme

(2018). CASP (insert name of checklist i.e. Randomised Controlled Trial) Checklist. [online] Available at:

URL. Accessed: Date Accessed.

©CASP this work is licensed under the Creative Commons Attribution – Non-Commercial- Share A like. To view a copy of this

license, visit http://creativecommons.org/licenses/by-nc- sa/3.0/ www.casp-uk.net

Critical Appraisal Skills Programme (CASP) part of Better Value Healthcare Ltd www.casp-uk.net

Section A: Are the results of the trial valid?

http://creativecommons.org/licenses/by-nc-

http://www.casp-uk.net/

http://www.casp-uk.net/


57

Is it worth continuing?

1. Did the trial address a clearly focused issue?

Yes HINT: An issue can be ‘focused’ In terms of • the population studied

Can’t Tell

No

• the intervention given

the comparator given • the outcomes considered

2. Was the assignment of

patients to treatments Yes HINT: Consider

how this was carried out randomised? Can’t Tell

No

was the allocation sequence concealed

from researchers and patients

3. Were all of the patients

who entered the trial Yes HINT: Consider

• was the trial stopped early properly accounted for at

its conclusion? Can’t Tell

No

• were patients analysed in the groups to which they were randomised

Comments:

Comments:

Comments:


58

Section B: What are the results?

4. Were patients, health

workers and study personnel

‘blind’ to treatment?

5. Were the groups similar at

the start of the trial

Yes

Can’t Tell

No

Yes HINT: Consider

• other factors that might affect the

6. Aside from the experimental

intervention, were the groups treated equally?

Can’t Tell

No

Yes

Can’t Tell

No

outcome, such as; age, sex, social class

Comments:

Comments:

Comments:


59

Comments:

Section C: Will the results help locally?

7. How large was the treatment effect? HINT: Consider

what outcomes were measured

Is the primary outcome clearly specified

what results were found for each outcome

8. How precise was the estimate of the treatment

effect? HINT: Consider

what are the confidence limits

9. Can the results be applied to

the local population, or in

Yes HINT: Consider whether

the patients covered by the trial are your context? Can’t Tell

No

similar enough to the patients to whom

you will apply this

how they differ

10. Were all clinically important

outcomes considered? Yes HINT: Consider whether

there is other information you would Can’t Tell

No

like to have seen

if not, does this affect the decision

Comments:

Comments:

Comments:


60

11. Are the benefits worth the

harms and costs? Yes HINT: Consider

even if this is not addressed by the Can’t Tell

No

trial, what do you think

self-compassion and treatments for anxiety disorders: a ...€¦ · preliminary evidence suggests...

Documents