by Allison C. Kelly, Ph.D. and Sydney Waring, M.A.
Department of Psychology, University of Waterloo, Canada
Many people with Anorexia Nervosa (AN) and other eating disorders do not seek formal treatment. Some reasons for not seeking help are external to the individual – for example, a lack of available and accessible treatments – whereas others are more internal. An individual may not fully recognize that they have an eating disorder or they may not be ready to let go of their eating disorder.
Indeed, the eating disorder wouldn’t be there if it wasn’t serving some function for the individual, such as “helping” manage painful feelings and insecurities. And yet, even if the eating disorder is helping in some way, it does not mean that the individual is not also suffering. So, for individuals who have an eating disorder but who may not be able or prepared to receive formal treatment for their eating disorder, is there anything they might do to cope better with the difficult feelings and insecurities they may have?
People are looking for a way to feel better
We set out to address this question by recruiting 40 people in the community who met DSM-5 diagnostic criteria for typical or atypical AN but who were not receiving treatment for their eating disorder. The study was advertised to people who were experiencing preoccupation related to their body and eating and who would be interested in participating in a two-week self-help intervention designed to help with daily distress.
Individuals did not have to self-identify as having an eating disorder or even want to get formal help for their eating disorder in order to sign up for the study. Amazingly, we were contacted by almost 600 people over the three-year study period (but only a small sub-set met our precise research criteria). This suggests that even if they are not seeking formal eating disorders treatment, people with AN and food and body image preoccupation are indeed looking for a way to feel better.
Writing a daily letter to oneself
The intervention we tested was adapted from compassion-focused therapy (CFT; Gilbert, 2005) and involved writing oneself a daily self-compassionate letter. Humans have an evolved ability to be compassionate, but it comes more easily to some than to others, in part based on how much care and warmth was available early in life. Compassion involves:
1) engaging with suffering by turning toward rather than away from it; and
2) acting in a way that can reduce and/or prevent suffering.
The Participants who were randomly assigned to our intervention learned about what compassion is, what benefits are associated with self-compassion (e.g., greater well-being, better coping), and what might make it difficult for people to cultivate self-compassion (e.g., worries about not being deserving of compassion). We asked everyone to reflect on their own personal pros and cons for becoming more self-compassionate, and encouraged them to see the study as an experiment with self-compassion.
Connecting with ‘compassionate self’
Every day, for two weeks, participants received a link to a survey webpage where they wrote themselves a compassionate letter. For each letter, they were asked to bring to mind a recent or current source of distress, and were then guided to get in touch with their “compassionate self” by recalling a time they felt compassionate toward someone else. Until they got the hang of cultivating compassion for themselves, they would first write a compassionate letter to someone else as a way of practicing compassion. Then, they would write a letter to themselves. In their letters, participants were asked to:
1) validate their suffering (e.g., “It’s understandable I’m having a tough time these days”);
2) see their suffering as something happening now but that will pass (e.g., “This is how I feel now but does not mean that’s how I will always feel”); and
3) express support and care for themselves (e.g., “I’m going to focus on reaching out to friends even though part of me feels like isolating myself”).
The daily letter helps to develop a compassionate inner voice
So, what did we find? First of all, we found that 19 of 20 participants (95%) stuck with the intervention for the full two weeks. Given that dropout rates tend to be closer to six times that in many eating disorders treatment programs, it seems our intervention was quite acceptable to participants. We also found that participants completed on average 75% of their daily letters. So, participants willingly engaged in this intervention, which is noteworthy.
But did the intervention actually help? The short answer is ‘yes.’ When we compared people who performed the letter-writing intervention to those in the wait-list control condition, we found that those who wrote a daily letter became more self-compassionate, less afraid of self-compassion, less ashamed (i.e., less worried about others’ judgments), and more personally motivated to seek out treatment for their eating and body image concerns.
The intervention did not impact actual concerns about weight, shape, and eating or dietary restraint, though we did find that BMI decreased in the wait-list condition but did not change significantly in the intervention condition. These findings suggest reveal that the letter-writing intervention is certainly not a replacement for specialized eating disorders treatment but can bring about some benefits for individuals who are not able or prepared to receive such treatment.
A stepping stone to learning more
Unfortunately, there are several things we still don’t know based on our study design. Was this intervention more effective than another intervention would have been? We only compared to a wait list condition, so it’s impossible to know. Did the intervention produce any lasting changes? We did not follow-up with people beyond the two weeks so we also don’t know. Finally, what percentage of people kept performing the intervention out of their own initiative, and what impact did this have?
In future research, we’re hoping to replicate this study but track people over longer periods of time. We’re also planning on seeing whether people who perform this letter-writing intervention before starting specialized eating disorders treatment are better able to benefit from treatment thanks to the more compassionate voice they now have in their head. It may be easier to face one’s fears (e.g., regaining weight, eating more regularly) when we are able to be caring and supportive towards ourselves.
Kelly, A. C., & Waring, S. V. (2018). A feasibility study of a 2‐week self‐compassionate letter‐writing intervention for nontreatment seeking individuals with typical and atypical anorexia nervosa. International Journal of Eating Disorders. doi: 10.1002/eat.22930
About Allison. I am a faculty member in the psychology department at the University of Waterloo where I study compassion and self-compassion, particularly as this pertain to body image and eating disorders. I’m also a practicing psychologist. I became very interested in compassion-focused therapy and compassionate letter-writing approaches through my clinical work with people who have eating disorders. I have found these to be powerful approaches in helping clients overcome feelings of shame and approach behavior change in a more caring and patient way.
About Sydney. I am a Ph.D. student in Clinical Psychology at the University of Waterloo. I started studying self-compassion in my Masters work where I investigated how interpersonal factors help or hinder our ability to be self-compassionate during difficult situations. In my future research, I hope to extend some of this work to the body image domain, and explore how the relationships we have with close others may impact our ability to feel positively about and appreciate our bodies. In my own life as a grad student and puppy mom, I find being self-compassionate really helps me to prioritize self-care and to stay balanced when daily life get stressful. Email: email@example.com
Diana has experienced eating disorders and recovery firsthand, with herself and her daughter. She co-founded The Diary Healer website with June Alexander and has written several blog posts based on her personal experiences in the hope that sharing her stories will give others a sense of community and connection, and give herself some perspective and healing along the way. If you would like to contact Diana, she can be reached at firstname.lastname@example.org