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Although people with an eating disorder are known to observe and assess body related stimuli, research has yet to explore these behaviours in the therapy room. Consequently, little is known about clients’ feelings about, and responses to, a therapist’s body, or the potential for a therapist’s body to have an impact upon the process and outcome of treatment. This lack of knowledge is problematic given client preferences and expectations can affect their willingness to engage in, and be influenced by, their therapist and the therapy process, and the fact that a fundamental part of the intra- and interpersonal experience of people with an ED is that of feeling invisible, unheard and worthless. It is also problematic given the poor recovery rates and high levels of drop out in eating disorders treatment and the fact that clinical guidance providers, researchers in the eating disorders (ED) field and individuals who have recovered from AN, all advocate psychological interventions as part of AN treatment. This study begins the process of redressing this omission by exploring ED clients’ beliefs regarding what is important about an ED therapist’s body weight and shape, eating behaviours and relationship with food. Twelve women who self-identified as recovered or on the road to recovery from AN, and had received counselling for their ED from a female therapist, participated in semi-structured interviews. Thematic analysis was used to analyse the data and three overarching themes were developed. The first theme – “Wearing Eating Disorder Glasses” – described the women’s observational tendencies. The second theme – “You’re Making All Sorts of Assumptions as a Client” – illustrated the women’s tendency to place great emphasis on body-related visual information when forming their opinions of, and beliefs about, a therapist. And the third theme – Appearance Matters – demonstrated the ways in which the women’s observation-based assumptions seemed to have potentially far-reaching implications for their attitude towards the therapeutic endeavour. Accordingly, the analysis offers preliminary evidence of a potentially important process taking place in the therapy room; namely, ED clients’ tendency to both observe their therapist’s body and eating behaviours, and make assumptions and judgements based on what they have seen. The analysis also suggests that ED clients’ assumptions and judgements may influence both their beliefs about their therapist’s ability to help them, and their willingness to engage in the therapeutic endeavour. Possible limitations of this study, areas for future research, and implications for practitioners in general and for counselling psychology and counselling psychologists in particular, are also discussed.

Over the recent years, research has documented links between eating disorder (ED) symptomatology and deficits in emotional functioning, with respect to the identification, differentiation and expression of affective states. Theoretical models of eating disorders have become increasingly sophisticated, alluding to the functional role of disordered eating in alleviating negative affect, through physiological and cognitive pathways. The aims of the study were a) to ascertain the specificity of emotional expression problems in women with ED, relative to women with depression and normal controls, b) to compare perceptions of threat posed by emotions among the three groups, c) to determine the relationship between emotional expression and perceptions of threat from emotion in the ED sample, and d) to extend a previous study (Hayaki et al., 2002a) to an ED sample, by exploring the relationship between emotional expression and body dissatisfaction, using a multiple hierarchical regression model.

Compassion Focused Therapy (CFT) was specifically developed for people with high levels of shame and self-criticism, who have difficulties with self-reassurance and self-compassion. It draws on evolutionary theories, particularly attachment theory, and neuroscience research of affect regulation. CFT has promising results with people with depression, psychosis and chronic mental health difficulties. However, the use of CFT has not been explored with people with eating disorders, who tend to be very self-critical and prone to experiencing shame. Therefore the aim of this research was to explore compassion in relation to eating disorders. To facilitate this, three related studies were undertaken. The aims of these studies were to: 1) Evaluate the outcomes of introducing CFT into a standard treatment programme for people with eating disorders in order to establish whether CFT can be used with this group of individuals. 2) Investigate the outcomes of a stand-alone Compassionate Mind Training (CMT) programme within a self-help setting and to explore participants' experiences of the programme. 3) Explore experiences of compassion from others in childhood, and current self- compassion, of people with eating difficulties. A mixed methodology approach was adopted, with repeated questionnaire measures used to investigate the outcomes of the interventions, and qualitative methods (specifically Interpretative Phenomenological Analysis) to explore the experiences of the CMT programme and experiences of childhood and current compassion. The results of Study 1 confirmed that CFT can be integrated into a standard treatment programme for people with eating disorders, with significant improvements in the cognitive and behavioural symptoms and psychopathological aspects of eating disorders, and more general psychological distress. This approach was particularly beneficial for people with bulimia nervosa or atypical eating disorders. Study 2 demonstrated that a CMT programme, which introduced the evolutionary model underpinning CFT and the specific training exercises included within the therapy, led to improvements on a range of questionnaire measures assessing eating difficulties, well-being, shame and self-criticism. Even though the programme did not focus specifically on eating difficulties, weight and shape concern both significantly reduced. This suggests that helping people to be more self-compassionate can impact on eating psychopathology. The qualitative data showed that the participants found the programme acceptable and benefitted from learning about the evolution of the brain and affect regulation systems. They also describe benefitting from the exercises and working as a group, which helped to develop a sense of safeness and allowed them to share their experiences. Study 3 identified six main themes, three relating to childhood experiences of compassion and three to current self-compassion. Participants recalled having difficulties in dealing with emotions from a very early age. In particular, they described how there was an interaction between their own temperament (e.g. concealment or withdrawal) and allowing their parents to be more emotionally engaged with them. Participants also experienced difficulties with current self- compassion, instead they tended to experience self-criticism and shame, and often used food to soothe themselves, either by restricting their eating or binge eating. To conclude, the research presented in this thesis provides the first evidence to support the use of GFT and GMT with people with eating disorders. It is also the first to explore experiences of the GMT programme and of people's early experiences of compassion and current self-compassion.

Literature Review: Emotional eating is being increasingly considered in the understanding of obesity and weight change (Ganley, 1989; Buckroyd, 2011). This review examined qualitative research grounded in emotional eating being a key factor of obesity and weight change. Six electronic databases were searched between August 2012 and January 2013. Included articles were published between 2000 and 2013 from the USA and Western Europe. Twenty-one articles were analysed using thematic analysis to integrate findings and generate relevant themes. Four core themes were identified: Vulnerability; Triggers; Function; and Emotional Aftermath. The findings indicated how emotional eating formed a cyclical pattern of behaviour with weight gain implicated as a primary consequence. Implications for future research and clinical practice are discussed. Research Report: Emotional eating was defined as van Strien et al. (2007) by 'the tendency to overeat in response to negative emotions such as anxiety or irritability' (p.106). The study aimed to explore women’s experiences of comfort eating, a form of emotional eating which provides self-comfort or self-soothing. Seven semi-structured interviews were conducted and analysed using Interpretative Phenomenological Analysis (IPA), finding three superordinate themes: ‘The private experience of comfort eating’; ‘My emotional relationship with comfort eating’; and ‘Mind-body connection’. Themes linked to comfort eating being used to mask (Polivy & Herman, 1999) or escape (Heatherton & Baumeister, 1991) negative emotion. Vulnerabilities to comfort eating included restrained eating (Herman and Mack, 1975) childhood eating patterns and critical parental rules around food. Implications for research and clinical practice are discussed. Critical Appraisal: The processes involved in conducting a research project are discussed reflectively in the critical appraisal section. This includes: personal reflections; limitations in terms of data collection and analysis; and implications for research and clinical practice.

Research has suggested that shame and self-criticism are important to eating disorders. Highly shame-prone individuals are thought to have difficulty feeling warmth for the self. Self-compassion is a new construct associated with being able to self-soothe and feel kindness for the self. To date, self-compassion has not been explored clinically in people with eating disorders, however, cognitive therapies have begun to incorporate related areas such as mindfulness.;The aim of the study was to explore relationships between eating disorder symptoms, internal and external shame, self-criticism variables (including self-reassurance) and self-compassion in a sample of women with eating disorders attending an outpatient specialist eating disorder service.;The study used a cross-sectional, correlational design. Seventy-six female participants completed a series of self-report measures assessing anorexic and bulimic cognition and behaviours, shame, self-criticism and self-compassion. Data were analysed using Pearson's Product Moment correlations.;There were significant relationships between anorexic cognitions and internal and external shame, and between anorexic cognitions and behaviours and types of self-criticism. Anorexic cognitions were significantly negatively related to self-compassion. Self-compassion was significantly negatively related to all the shame and self-criticism variables, and positively related to self-reassuring. Self-compassion may protect against anorexic cognitions and associated beliefs associated with shame and self-criticism.;Conclusions: Women with eating disorders are highly shame-prone and engage in self-critical thinking. Self-compassion may be a clinically useful construct but this requires further research.

The current study aimed to consider the application of the cognitive-interpersonal framework (Safran, 1990a, 1990b) to further the understanding of eating disorders, by exploring interpersonal schemas of individuals with and without eating disorders. Three groups of females (non-dieters, dieters and clinical eating disorders) were recruited to participate in the study and aimed to reflect a proposed spectrum of eating distress. Individuals completed the Interpersonal Schema Questionnaire, (ISQ; Hill and Safran, 1994) which assessed expectations about how significant others would respond in certain situations. The current study employed a Multivariate Analysis of Variance (MANOVA) to explore differnces in interpersonal schemas between the three groups. Results indicated that individuals with eating disorders differed from non eating-disordered individuals on the type of responses expected from significant others, the degree of complementarity within those responses and how desirable they experienced those responses. Overall, individuals with eating disorders presented with 'hostile' interpersonal schemas indicating that they expected more hostility from others in a variety of situations. Results are discussed within a cognitive-interpersonal framework (Safran, 1990a, 1990b). It appeared that individuals with eating disorders were 'stuck' in unhelpful ways of relating that were reinforced through `hostile' interpersonal schemas. It is suggested that individuals may regenerate their eating disorders through such perpetuating cognitive-interpersonal cycles. The current study strengthens the argument for the combination of cognitive and interpersonal theories to enhance the effectiveness of the assessment and treatment of eating disorders. Additionally, results invite further research on interpersonal cognition and the role of such in eating disorders.