Body dissatisfaction, stigma and eating disorders: a scoping study on the role of compassion focused therapy

Abstract

Despite Cognitive-Behavioural Therapy (CBT) being the gold standard for treating eating disorders (ED), approximately 50% of patients do not see significant results. Increased body-related stigma in society, driven by a pursuit of thinness for peer acceptance, has led to substantial rises in body image dissatisfaction, which is closely linked with EDs like Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED). This issue needs addressing in treatment as societal pressures cause individuals to internalise stigma. Compassion Focused Therapy (CFT), which emphasises a compassionate self-approach, might be a suitable alternative to CBT, focusing more on body image acceptance and potentially breaking the shame-cycle caused by stigma. This study compiled current literature on CFT’s role in addressing body image dissatisfaction and stigma in ED patients. 8 studies with 637 female and 14 male participants were reviewed. Results showed that CFT-combined approaches reduced body image dissatisfaction and ED pathology, particularly in young adult females with BED. Participants noted that stigma and fear of judgement hindered ED treatment but recognised that increased self-compassion could mitigate these effects. The study highlighted the need for more diverse and broader participant samples, and standalone CFT studies, to enhance the generalisability of results and expand upon the current research pool of CFT uses for body image in eating disorders. In conclusion, CFT shows promise as an alternative method to reduce stigma and treat body image dissatisfaction in ED populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40337-025-01292-0.

Plain language summary

Cognitive Behavioural Therapy (CBT) is often used to treat eating disorders (EDs) but doesn’t have good outcomes for about half of patients. Society’s focus on thinness has been linked to more people being unhappy with their bodies, particularly with EDs. This study reviewed the effectiveness of Compassion Focused Therapy (CFT) as an alternative to CBT. CFT encourages people to be more compassionate towards themselves, aiming to improve body image acceptance and reduce the shame associated with stigma. Eight studies involving 651 individuals with eating disorders were included. Results showed that CFT reduced body image concerns and ED symptoms, especially in young adult women with binge eating disorder (BED). However, the pool of studies was small, impacting the generalisability of these results. Stigma from society and fear of judgement were shown as barriers in treatment, but increased self-compassion helped. This study highlights that more diverse samples are needed to generalise findings and challenge the stereotype that EDs only affect certain groups. Overall, CFT appears promising for addressing stigma and improving body image in ED patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40337-025-01292-0.

Introduction

Eating disorders, characterised by persistent disturbances in eating behaviours and associated distress [1], continue to present a significant challenge to mental health professionals worldwide [2–4]. It can be difficult to gather a true estimate for eating disorder prevalence due to those affected avoiding or postponing clinical care for their condition, partially through fear of being judged by the stigma surrounding weight/shape [5–7], making them much more difficult to recognise until later in their course of illness and leading to unreported cases. However, we do know that eating disorders can affect any individual- with occurrences in culturally, ethnically, and socioeconomically diversified backgrounds [8]. Among the multifaceted complexities of these disorders, body image concerns and self-criticism stand as prominent and often debilitating features, contributing to the maintenance and exacerbation of disordered eating behaviours [9].

Cognitive Behavioural Therapy (CBT) is currently seen as the gold standard treatment in treating many mental health concerns, including addressing eating disorders, and shows significant improvements for approximately 50% of patients [10]. More recent assessments on the use of CBT also show similar results in individuals with bulimia nervosa and atypical eating disorders [11]. This indicates a need to explore alternative therapies offered in eating disorder treatment in order to address the remaining 50% of patients not seeing significant improvements [12, 13]. In recent years, there has been a growing recognition of the role of compassion in the prevention and treatment of eating disorders [14]. One form of compassion-focused treatment is Compassion Focused Therapy (CFT), rooted in evolutionary psychology and Buddhist principles, which has emerged as a promising therapeutic approach aimed at cultivating compassion towards oneself and others [15–17]. CFT is categorised within the ‘third-wave’ of cognitive and behavioural therapies, prioritising mindfulness, acceptance, meta-cognition, emotions, values, and goals [18]. However, its specific application in the context of body image concerns with eating disorder populations remains relatively unexplored.

When discussing eating disorders, it’s important to acknowledge that stigma plays a role in the onset and maintenance, and can come in different forms. Weight-based stigma, referring to the negative attitudes and discrimination individuals face based on their body weight or shape, is one of the more prominent forms. Research shows that weight-based stigma can lead to body dissatisfaction, shame, and increased risk for developing eating disorders, particularly those who experience weight-based bullying or discrimination [19–21]. Similarly, perceived stigma, the belief that others stigmatise them because of their body weight or appearance, can cause emotional distress [22, 23], while internalised stigma occurs when individuals adopt society’s negative attitudes towards themselves. Internalised stigma often exacerbates feelings of inadequacy and fuels eating disorder behaviours [23]. The overemphasis on Body Mass Index (BMI) as a standard measure of health further contributes to weight-based stigma [19, 23]. Individuals categorised as overweight or obese based on their BMI are frequently subjected to negative judgement, increasing the likelihood of internalised stigma and body dissatisfaction, which can lead to disordered eating behaviours [19]. On the other hand, those within the “normal” BMI range may still struggle with body image issues if they perceive themselves as failing to meet societal ideals of thinness, perpetuated by the glorification of thinness in media and culture [19, 24]. This creates a cycle of dissatisfaction, where individuals with both higher and “normal” BMIs may engage in restrictive dieting or excessive exercise in an effort to conform to societal ideals, further contributing to the development and maintenance of eating disorders [19, 25]. In this context, body image problems, fuelled by both weight-based stigma and cultural pressures to attain a specific body type, often lead to poor self-esteem and disordered eating, perpetuating the cycle of the illness [26].

Part of this study’s purpose is to explore research not only on how CFT has been used in the treatment of body image concerns in eating disorders, but also to explore the role and views of compassion itself within these eating disorder interventions. As part of this study’s interest, the analysis touches upon whether and how stigma related to body image and eating disorders has been addressed in these compassion-focused treatments, given what is known about its role in the onset and maintenance of eating disorders; therefore, some studies may not explicitly include references to stigma. This dual focus on both the application of compassion-focused treatment and CFT, and its relationship with stigma and eating disorders, builds upon Steindl’s 2017 study [27], which focused primarily on the role of compassion in general mental health treatment but not the specific application to body image concerns in eating disorders. In the current study, compassion-focused treatment is defined as an approach which integrates techniques aimed at developing self-compassion, addressing shame, and reducing self-criticism, particularly regarding eating disorders and body image. Compassion-focused treatments are designed to help people create a more accepting relationship with themselves, often using compassionate mind training, which has evidence in reducing self-criticism and improving emotion regulation [28].

Traditional treatments, such as CBT, often focus on symptom reduction without fully addressing the underlying emotional and psychological factors that maintain dissatisfaction with body image [29, 30]. CFT offers an alternative approach by emphasising the use of self-compassion, acceptance, and mindfulness as means to reduce distress and encourage a more positive body image through building a more compassionate state-of-mind [16, 17, 28, 31].

CFT offers a unique lens through which to understand the psychological processes underlying body image concerns and eating disorders by examining the interplay between three interconnected systems: the threat system, the drive system, and the soothing system [16, 17]. Structured CFT, opposed to more general compassion-focused treatment, often has a focus on these systems. The threat system, rooted in evolutionary biology, is responsible for detecting and responding to potential threats in the environment. In the context of body image and eating disorders, this system may become overactive, leading individuals to perceive their bodies as threats and triggering maladaptive responses such as self-criticism and avoidance behaviours. The drive system, on the other hand, is associated with the pursuit of goals and desires, including the drive for social acceptance and validation. Research has shown that high levels of weight dissatisfaction, the drive for thinness that has been intensified by access to social media and thin ideation, can lead to the weight stigma becoming more internalised [32–34]. In individuals with body image concerns or eating disorders, this system may manifest as an intense desire for thinness or an idealised body shape to retain social favour by fitting in with society’s beauty standards [35], fuelling restrictive eating patterns or excessive exercise regimes. Finally, the soothing system encompasses the capacity for self-soothing, kindness, and compassion towards oneself and others. In the context of body image and eating disorders, deficits in this system may contribute to a lack of self-compassion and perpetuate cycles of shame and self-criticism [31]. By addressing imbalances and dysregulation within these systems, CFT aims to cultivate a more compassionate and balanced relationship with one’s body, fostering acceptance, self-kindness, and emotional regulation. Individuals can learn to soothe their threat and drive systems, thereby reducing body image distress and promoting healthier relationships with food and their bodies. This demonstrates how CFT may be a good alternative option for CBT in treating eating disorders as its primary focus is on an individual’s underlying emotional and psychological concerns opposed to symptom reduction.

CFT works with the notion that individuals with eating disorders are often trapped in cycles of self-criticism, shame, and perfectionism, perpetuating their negative body image. These feelings of shame and criticism can cause an individual to feel a fear of compassion towards themselves and to fear this from others, interfering with their ability to engage in compassion-focused exercises [28, 37]. By fostering a compassionate stance towards oneself, CFT aims to disrupt these maladaptive patterns and cultivate a more balanced and accepting relationship with one’s body. Drawing on techniques such as compassionate imagery, compassionate mind training, and compassionate self-talk, CFT provides practical tools for individuals to develop a kinder and more supportive inner dialogue, providing a barrier against both internal and external shame.

One of the more recent comprehensive reviews of CFT examined the efficacy and acceptability of CFT within clinical populations [38]. This review included 29 studies on CFT published between 2004 and 2019: 9 randomised controlled trials (RCTs), 3 non-randomised trials, and 17 observational studies. The findings consistently demonstrated the positive impact of CFT on mental health outcomes across different clinical contexts. These included populations struggling with substance misuse disorders, individuals with brain injuries, and parents of children diagnosed with neurodevelopmental disorders. Notably, group therapy emerged as a favoured mode of CFT delivery within these studies. In addition, Millard et al.’s 2023 systematic review and meta-analysis [39] examined effect sizes of CFT for treating eating disorders. Their findings show moderate to large effect sizes for CFT in reducing eating disorder symptoms and body dissatisfaction, providing further supporting evidence for the use of self-compassion in eating disorder treatment. Whilst this study focused primarily on exploring the efficacy of CFT by looking at quantitative outcomes in symptom reduction, our study aims to build upon this by exploring how CFT has been applied to body image concerns in eating disorders, and exploring the role and perception of compassion within these treatments. We aim to understand how different studies conceptualise and incorporate compassion in therapeutic settings and whether the issue of stigma is addressed in these studies. By undertaking a scoping review, this study aims to explore and consolidate available evidence, thereby providing a holistic understanding of the current state of research in this area.

Through this endeavour, we aim to identify key themes and condense current research findings to answer the following research question: “What is known about CFT in targeting body dissatisfaction and mitigating stigma in eating disorders?”. This will entail mapping existing research, identifying the gaps and inconsistencies in the literature, and subsequently areas for future investigation. Ultimately contributing to the enhancement in the quality of care provided for individuals struggling with eating disorders and body image concerns. While studies claims of efficacy may be discussed, this study does not attempt to assess the efficacy of compassion-focused treatment on addressing body image concerns or stigma in eating disorders.

Method

Search strategy

This scoping study was pre-registered (DOI removed for peer review) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines which were followed during the search, review, and reporting processes [40, 41]. The search strategy was formulated during regular meetings and consultations between the primary author and the secondary author from Autumn 2023 to Spring 2024. Preliminary searches were conducted using the NHS Knowledge and Library Hub, looking at the following possible databases: PsycINFO, PubMed, Scopus, Web of Science, Google Scholar, PsycARTICLES, ERIC: Education Resources Information Center, CINAHL: Cumulative Index to Nursing and Allied Health Literature), Complementary Index, Health and Medicine, Psychology and Behavioural Sciences Collection, EThOS, and ScienceDirect to identify potential articles about eating disorders, body image, and compassion-focused treatments. These databases were selected due to accessibility with NHS licences, any that weren’t included were due to being inaccessible to the authors at the time of writing. During these searches, the following bases were identified as most useful for identifying potentially relevant articles: PsycARTICLES, PubMed, Complementary Index, and Psychology and Behavioural Sciences Collection. To search the database, the following subject terms were used: “Compassion focused therapy” OR “CFT” OR “Compassion”, AND, “Body image” OR “Self-esteem” OR “Self-image” OR “Body dissatisfaction”, AND, “Eating disorders” OR “ED” OR “Anorexia” OR “Anorexia Nervosa” OR “AN” OR “Bulimia” OR “Bulimia Nervosa” OR “BN” OR “Disordered eating” OR “Binge eating disorder” OR “BED”. No limits were set on the date of publication and duplicated studies were automatically filtered out by the database. The initial search began in September 2023 and was followed-up with another search using the same methods in March 2024 to capture any new studies that may have been published.

Inclusion and exclusion criteria

Articles included in this review met the following criteria: 1) published in peer review journals; 2) published in the English language by March 2024; 3) is either a case study, doctoral or master’s theses, report, primary research, service audit or evaluation, or empirical literature; 4) has a population sample that includes participants with a diagnosis of an eating disorder; 5) has a focus on body dissatisfaction as a measure (if this is included in another measure, the corresponding sub-score is reported); 6) has a focus on treating body image concerns or stigma with compassion-focused work.

The following types of studies were excluded from the review: newspapers; conference or meeting abstracts, commentaries, editorials, or letters; undergraduate theses; literature reviews; book chapters; articles which are not published in a peer-reviewed journal or peer-review status is unclear; non-empirical literature; non-English language studies; studies that did not focus on an eating behaviour or disorder measurement and did not report on an individual body image measurement, or use of compassion; studies that did not have a diagnosed eating disorder population and instead focused on disordered eating patterns in the general population; studies with a focus only on shame or self-esteem over body dissatisfaction; studies examining individuals with other types of neurodevelopmental, medical, or mental health diagnoses following compassion-focused treatment; or studies focused on the risk of developing an eating disorder instead of treating an existing eating disorder.

Review procedure and analysis

Articles were initially identified by analysing the abstracts for key information based upon the inclusion/exclusion criteria and then entered into an excel table by the primary author. Any discrepancies were resolved by the primary and secondary authors. Full-text reviews were then completed by the primary author and agreed with the secondary author again. The excel table included the following categories: Title, Author(s), Year, Database, Abstract, Search Words, Key Words, Journal/Source, DOI/URL, Study Type, Research Questions/Objectives, Methods, Sample/Participants, Findings/Results, Relevance, and Further Notes. Data extraction was completed by the primary author and agreed upon by the secondary author. No formal inter-reliability measures were used for this process – authors agreed on coding criteria together. Duplications were removed initially by the search engine. Then any outstanding duplicates were removed manually; in this process, one study was de-duplicated. Another paper came to view after initial searches during the peer review process, but was subsequently excluded. This paper is addressed in the discussion. The PRISMA figure (see Fig. 1) outlines the course of the review and article selection and extraction.

Fig. 1.

Figure of search process

Data was then manually pulled from each paper to a spreadsheet developed by the primary author where the Title, Author(s), Year, Key Focus, Sample, Study Type, Quantitative Methods, Qualitative Methods, Key Findings, and Themes were noted. This provided a clearer picture of any patterns or differences between the included articles, when critiquing the current body of literature on CFT in addressing body image dissatisfaction within eating disorder populations, considering the role of stigma. Data was narratively summarised from these outcomes in an additional table used to synthesise the results of the articles based upon our review questions.

Results

The review identified 8 articles [42–49] for inclusion (see Table 1 for PRISMA figure on the characteristics of included sources of evidence, Table 2 for results of individual sources of evidence and Table 3 for synthesis of the evidence). Of these 8 studies, 2 look at CFT combined with CBT or TAU [43, 49], and the remaining 6 look at compassion-focused interventions or the role of compassion in eating disorder treatments for body image concerns. The results section is organised by areas of analysis – method analysis of studies (including sample demographics, quantitative methods and qualitative methods) and summary results by topic area (including eating disorder treatment, self-compassion, and body image).

Table 1.

Characteristics of included sources of evidence

Title	Author(s)	Year	Key Focus	Sample Demographics	Study Design	Quantitative Measures	Qualitative Measures
Self-Compassion in the Face of Shame and Body Image Dissatisfaction	Ferrieira, C., Pinto-Gouveia, J., & Duarte, C	2013	Self-Compassion and Body Image and Eating Disorders	102 female eating disorder patients (M = 23.62, SD = 7.42) with a BMI range of 13.32 – 47.33 kg/m2 (M = 21.15, SD = 6.93); 32.4% Anorexia Nervosa, 30.4% Bulimia Nervosa, 37.2% EDNOS, 123 women from the general population (M = 23.54, SD = 6.89)	Cross-Sectional Correlational Study	Self-Compassion Scale (SCS), Other as Shamer Scale (OAS), Depression, Anxiety and Stress Scales (DASS42), Eating Disorder Inventory (EDI), Eating Disorder Examination 16.0D (EDE 16.0D),	N/A
An Evaluation of the Impact of Introducing Compassion Focused Therapy to a Standard Treatment Program for People with Eating Disorders	Gale, C., Gilbert, P., Read, N., & Goss, K	2012	Compassion Focused Therapy and Eating Disorders	99 participants (M = 28.01, SD = 8.67, range = 17–62 years). Included 95 females and 4 males, EDNOS (54.5%), Anorexia Nervosa (19.2%), and Bulimia Nervosa (26.3%)	Repeated Measures Design	Eating Disorder Examination Questionnaire (EDE-Q), The Stirling Eating Disorder Scale (SEDS), The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM)	N/A
Are Improvements in Shame and Self-Compassion Early in Eating Disorders Treatment Associated with Better Patient Outcomes?	Kelly, A. C., Carter, J. C., & Borairi, S	2013	Self-Compassion and Eating Disorders	DSM-IV-TR criteria for an eating disorder 97 participants, predominantly female (97%—94), Age M = 28, SD = 9.6 27.2% AN restricting type, 18.5% AN binge-purge, 29.6% bulimia nervosa, 24.7% EDNOS. BMI range 12.6–44	Longitudinal Study	Eating Disorder Examination Questionnaire (EDE-Q), Experiences of Shame Scale (ESS), Self-Compassion Scale-Short Form (SCS-SF)	N/A
Self-Compassion Training for Binge Eating Disorder: A Pilot Randomized Controlled Trial	Kelly, A. C., & Carter, J. C	2015	Compassion Focused Therapy and Binge Eating Disorder	Meeting DSM-5 criteria for BED, 18 +  41 participants (34 female), M = 45, SD = 15	Pilot randomized controlled trial	EDE-Q, Binge Eating Frequency, Self-Compassion Scale, Center for Epidemiological Studies for Depression, Fears of Compassion Scale, Credibility/Expectancy Questionnaire, Homework Rating Scale	N/A
Group-Based Compassion-Focused Therapy as an Adjust to Outpatient Treatment for Eating Disorders: A Pilot Randomized Controlled Trial	Kelly, A. C., Wisniewski, L., Martin-Wagar, C., Hoffman, E	2016	Compassion Focused Therapy and Eating Disorders	Meeting DSM-IV-TR criteria for an eating disorder, 18 + . 22 participants (M = 36.73, SD = 12.58)	Pilot randomized controlled trial	Credibility and Expectancy Questionnaire, CFT Feedback Questionnaire, EDE-Q, Self-Compassion Scale, Fears of Compassion Scale, Experiences of Shame Scale	N/A
Why Would I Want to Be More Self-Compassionate? A Qualitative Study of the Pros and Cons to Cultivating Self-Compassion in Individuals with Anorexia Nervosa	Kelly, A., Katan, A., Sosa Hernandez, K., Nightingale, B., & Geller, J	2020	Self-Compassion and Anorexia Nervosa	DSM-5 criteria for Anorexia Nervosa 37 female participants with typical (64%,) and atypical (36%) anorexia nervosa (M = 21.6, SD = 2.62)	Qualitative Study/Thematic Analysis	N/A	After listening to an audio guide on self-compassion, participant typed out their personal pros and cons with becoming more self-compassionate
Body Appreciation and Intuitive Eating in Eating Disorder Recovery	Koller, K. A., Thompson, K. A., Miller, A. J., Walsh, E. C., & Bardone-Cone, A. M	2020	Body Image and Eating Disorders	Final sample: 63 females with an eating disorder. 31 control group participants. (Age at start of treatment M = 18.03, SD = 4.5)	Cross-sectional study	Body Appreciation Scale, Intuitive Eating Scale-2	N/A

Title	Author (s)	Year	Key focus	Sample Demographics	Study Design	Quantitative Measures	Qualitative Measures
Befree: A New Psychological Program for Binge Eating that Integrates Psychoeducation, Mindfulness, and Compassion	Pinto-Gouveia, J., Carvalho, S. A., Palmeira, L., Castilho, P., Duarte, C., Ferreira, C., Duarte, J., Cunha, M., Matos, M., & Costa, J	2017	Self-Compassion and Boy Image and Binge Eating Disorder	Befree group (N = 19, M = 42.72, SD = 9.94) and Waiting List Group (N = 17, M = 41, SD = 9.56)	Efficacy Pilot Study	EDE 16.0D, Binge Eating Scale, Beck Depression Inventory-I, Other as Shamer Scale, Obesity-Related Well-Being Questionnaire, Body Image-Acceptance and Action Questionnaire, Cognitive Fusion Questionnaire-Body Image, Engaged Living Scale, Self-Compassion Scale, Five Facet Mindfulness Questionnaire-15	N/A

Table 2.

Results of Individual Sources of Evidence

Title	Key findings	Themes
Self-Compassion in the Face of Shame and Body Image Dissatisfaction	Higher levels of self-compassion linked to lower levels of body image dissatisfaction and lower engagement in eating disorder behaviours	Role of Self-Compassion; Association with Shame and Body Image Dissatisfaction; Differences between Groups; Affiliative Emotion Dimensions
An Evaluation of the Impact of Introducing Compassion Focused Therapy to a Standard Treatment Program for People with Eating Disorders	Significant improvements across all questionnaire measures following CFT treatment, with bulimia nervosa seeing the most improvement	Compassion Focused Therapy; Positive Outcomes; Differential Improvement by Diagnosis; Challenges in Addressing Self-Criticism; Focus on Self-Criticism, Shame, and Self-Compassion
Are Improvements in Shame and Self-Compassion Early in Eating Disorders Treatment Associated with Better Patient Outcomes?	Bigger decreases in shame showed faster decreases in eating disorder symptoms	Compassion Focused Therapy; Theory of Shame and Self-Compassion; Relationship Between Shame and Eating Disorder Symptoms
Self-Compassion Training for Binge Eating Disorder: A Pilot Randomized Controlled Trial	Self-compassion intervention reduced eating disorder symptoms including weight and shape concerns	Role of Self-Compassion; Feasibility and Efficacy of Interventions; Impacts on Binge Eating and Psychological Vulnerability; Effects on Self-Compassion
Group-Based Compassion-Focused Therapy as an Adjust to Outpatient Treatment for Eating Disorders: A Pilot Randomized Controlled Trial	Group CFT in combination with treatment as usual reduced levels of shame, fears of compassion and self-compassion, and eating disorder symptoms more than the control group	Feasibility and Acceptability of CFT Group Intervention; Shame, Self-Compassion, and Eating Disorder Pathology; Supplementing TAU with CFT
Why Would I Want to Be More Self-Compassionate? A Qualitative Study of the Pros and Cons to Cultivating Self-Compassion in Individuals with Anorexia Nervosa	Perceived cons include apprehension and doubt about the efficacy of self-compassion and the emotional challenges with developing this skill. Perceived pros include improved health, personal development, improved outlook and better relationships	Perceived Pros and Cons of Self-Compassion; Fear of Personal Shortcomings; Emotional Challenges; Perceived Personal and Interpersonal Benefits; Enhanced Personal Development; Interpersonal Relationships
Body Appreciation and Intuitive Eating in Eating Disorder Recovery	Greater body appreciation linked to lower levels of negative body image and eating disorder symptoms	Positive Body Image in Eating Disorder Recovery; Association between Recovery and Positive Constructs; Different Facets of Intuitive Eating; Association with Stability of Recovery
Befree: A New Psychological Program for Binge Eating that Integrates Psychoeducation, Mindfulness, and Compassion	Treatment showed decreases in levels of binge eating severity and eating psychopathology, as well as lower levels of negative body image, body-image cognitive fusion, and self-criticism	Befree; Positive Outcomes; Psychological Processes; Self-Compassion

Table 3.

Table of synthesis of evidence based on review questions

Review question	Summary of results
How is CFT implemented in interventions targeting body image dissatisfaction among individuals with eating disorders, taking into account the stigma associated with both the disorders and body image issues?	Experiential studies looking into the effects of Compassion-Focused Therapy show group intervention plans typically last between 12–20 sessions long With the few studies who implemented their own CFT trials [43, 49], CFT was combined with CBT or Treatment as Usual (TAU), opposed to being a standalone intervention. CBT alone only achieves clinically significant improvements in about 50% of patients [10]; therefore, the addition of CFT may be useful in breaking the shame-symptom cycle existing for the remaining 50% of patients. This approach aims to capitalise on the strength of each therapeutic modality whilst addressing the unique emotional and relational factors underlying body image dissatisfaction by addressing stigma-related barriers to recovery One intervention included an outline of the intervention, a focus on psychoeducation, values clarification, experiential distancing acceptance and willingness, mindfulness, and compassion. Compassion was brought in at session 10 out of 12 [49] Another intervention introduced self-compassion earlier into the programme. This outline included an orientation to treatment with relevant psychoeducation, development of group purpose and the introduction of CBT model, self-monitoring and de-shaming discussions, focusing on ED risks with problem solving, introducing CFT and compassionate interventions imagery with distress tolerance skills, and relapse prevention. Compassion was brought in as a focus in session 7 out of 20 [43]
What are the key findings regarding the effectiveness of Compassion Focused Treatment in addressing body image dissatisfaction within eating disorder populations, considering the role of stigma?	The role of stigma exacerbates body image dissatisfaction and a drive for thinness, which can be an initial con for patients when deciding to commit to compassion-focused treatment. AN patients particularly worry how self-compassion may cause them to give up their efforts to conform to society’s ‘thin ideal’, despite perceived benefits in having more of a sense of self [47] Individuals who build a more compassionate self-to-self relationship show lower levels of body image dissatisfaction and reduced engagement in eating disorder behaviours [42−46, 48, 49] Individuals who have taken part in CFT treatment show reductions in internal shame, external shame and self-criticism, with an increase in self-compassion, impacting upon symptoms of eating disorder psychopathology [43, 49]. Further research is needed to understand these links to the role of the shame-symptom cycle maintaining ED pathology Self-compassion as a mediating factor in the relationship between external shame and drive for thinness, acting as a buffer against the effects of stigma – a potential use of compassion to help with feelings of inferiority and drive for thinness Those who experience larger decreases in their levels of shame and greater increases in their level of self-compassion in the first 4 weeks of treatment show faster decreases in their eating disorder symptoms over 12-weeks of treatment. Findings were found in a mixed sample of eating disorders (AN-R, AN-BP, BN, EDNOS – BED) [43] Participants who have a relatively low baseline fear of self-compassion had the greatest improvements in ED pathology and depressive symptoms when in self-compassion treatment [43]

Method analysis

Sample characteristics

Across the 8 studies, there were a total of 637 female participants and 14 male participants (a ratio of 46:1). It’s noteworthy that only 2 of the 8 included studies included male participants, and they also made up the minority of the samples they were included in. Of the total 651 individuals, 171 participants were control participants and 480 were diagnosed with an eating disorder. An analysis of eating disorders shows the following representation of eating disorders in the sample populations for the included studies: 133.3 AN (27.7%), 85.7 BN (17.9%), 176 EDNOS (36.7%), 85 Unspecified ED (17.7%). Whilst nearly half of the samples do represent individuals with AN and BN, the largest diagnosis represented in these studies is EDNOS/BED. When looking at the age of individuals included, we can see a wide range of ages included (approximately 17–62), with the mean age sitting at 30.46 years. In addition, the included studies cover a limited number of regions, particularly under Western influence: the UK, Portugal and Canada.

Quantitative methods

All except one of the papers [42–46, 48, 49] involved in this review relied upon quantitative measures, with the main studies being a mix of cross-sectional correlational studies, repeated measures designs, pilot randomised controlled trials, or longitudinal studies. Several different measures were used to assess the variables of interest – the most common measures used across all of the 7 quantitative studies include: the Self-Compassion Scale (SCS), and the Eating Disorder Examination Questionnaire (EDE-Q). Outstanding measures used in 2 or less studies can be found in Table 1.

Qualitative methods

Only one study [47] in this scoping literature review detailed qualitative findings; this study involved patients typing out their perceived pros and cons of engaging in self-compassion as part of treatment. It’s important to note that this study involved questions about a hypothetical treatment and does not evaluate the participants’ views from actual experience of having received a treatment involving self-compassion; however, the results do provide insight into potential barriers to treatment.

Key findings

Compassion in treatment

Experiential studies investigating the effects of CFT typically implemented group intervention plans lasting between 12 to 20 sessions [43, 49]. In these studies, CFT was often combined with CBT or Treatment as Usual (TAU), rather than being used as a standalone intervention. This combined approach was intended to leverage the strengths of each therapeutic modality while addressing the emotional and relational factors underlying body image dissatisfaction and stigma-related barriers to recovery. The addition of CFT aimed to address the shame-symptom cycle.

One group intervention [49] outlined a comprehensive plan that included psychoeducation, values clarification, experiential distancing, acceptance and willingness, mindfulness, and compassion. Compassion-focused strategies were introduced in session 10 of the 12-session programme. Initial results saw little benefits from the introduction of compassion on body image; however, by 6-months following the treatment, results suggested significant improvements supported by medium-large effect sizes from their ANOVA. This included patient’s reporting an elimination of binge eating episodes, a notable decrease in disordered eating behaviours and attitudes, lower levels of shame and self-critical thoughts, an increased ability to recognise thoughts related to body image and to not over-identify with these, and improved levels of self-compassion.

Another group intervention [43] introduced self-compassion earlier in the programme and saw statistically significant results supported by large effect sizes in decreasing body dissatisfaction and eating disorder pathology by 12-weeks of treatment. This intervention included an orientation to treatment with relevant psychoeducation, development of group purpose, introduction to the CBT model, self-monitoring, de-shaming discussions, focus on eating disorder risks with problem-solving, and the introduction of CFT and compassionate interventions through imagery and distress tolerance skills. Compassion became a focal point starting in session 7 of the 20-session programme.

In contrast, the qualitative study regarding perceived pros/cons of developing self-compassion as part of treatment with AN provided insight into potential barriers to engaging in treatment [47]. The results from this study highlighted a hypothetical worry that practicing self-compassion may result in them giving up their efforts to conform to society’s ‘thin ideal’. However, patients recognise that the benefits of self-compassion could involve developing more of a sense of self and improving their quality of life.

CFT, eating disorders, body dissatisfaction and shame- key findings

The studies included yielded several key insights into the impact of CFT on individuals with eating disorders. The findings across all studies highlight the role of fear of judgement in exacerbating body image dissatisfaction and drive for thinness, posing a substantial initial barrier to treatment commitment [42–49]. Evidence from these studies suggests that fostering a compassionate self-to-self relationship may be a mitigating factor for these issues. Participants in CFT-related treatments also reported notable reductions in internal and external shame [43, 49], self-criticism and eating disorder symptoms, alongside increased self-compassion. The interplay between self-compassion, shame, and ED symptoms emerged as a key factor in treatment outcomes, providing an understanding of CFT’s potential therapeutic benefits.

Participants undergoing CFT treatment demonstrated reductions in internal shame, external shame, and self-criticism, along with increases in self-compassion [43, 49]. These changes were associated with improvements in symptoms of eating disorder psychopathology, such as lower weight/shape concerns. Notably, only 4 studies [42, 46, 48, 49] explicitly discussed the role of stigma in their results/discussions sections, with 1 study alluding to links [47], and the remaining 3 having limited discussion [43–45].

A key theme in these studies focuses on self-compassion being a potential mediating factor in the relationship between external shame and drive for thinness, acting as a buffer against the effects of stigma [42–49]. This mediation potentially benefits patients by alleviating feelings of inferiority and reducing the drive for thinness [42–49].

Those who experienced larger decreases in shame and greater increases in self-compassion during the first four weeks of treatment showed faster reductions in eating disorder symptoms over a 12-week treatment period [49]. These findings were consistent across a mixed sample of eating disorders (AN-R, AN-BP, BN, EDNOS – BED).

Moreover, participants with relatively low baseline fear of self-compassion were reported to experience the greatest changes in eating disorder pathology and depressive symptoms during self-compassion treatment [43]. This underscores the importance of addressing the fear of self-compassion early in the therapeutic process.

Outcomes showed a reduction in body image dissatisfaction and eating disorder pathology with the addition of self-compassion to treatment [42–46, 48, 49]. BED/BN patients initially reported bigger changes—however, all patients showed a catch-up within 6-months post-treatment, suggesting some individuals/eating disorder subtypes may take longer to adapt to changes [49].

Discussion

This scoping study reviewed the current available research on the application of Compassion-Focused Therapy in treating eating disorders, particularly in targeting body image issues and how they address the issue of stigma. Stigma has been seen to be a significant barrier to seeking and receiving treatment in individuals with eating disorders, due to the fear of judgement on moving away from social norms [50]; by fostering self-compassion and reducing self-criticism, CFT aims to help individuals cultivate a more positive self-image [51]. This study only identified 8 studies which fit the criteria of looking at compassion-focused treatment in treating eating disorders, with a focus on addressing body image concerns and considering the role of stigma. Of these 8 studies [42–49], only 2 included clinical trials of CFT with patients [43, 49], and neither of these studies used CFT as the standalone intervention. This limits the ability to which the results can be generalised to real-world scenarios, and brings attention to a gap in research which needs further exploration. The findings in the included studies demonstrated improvements in both body image and eating disorder symptoms with the use of compassion in treatment, indicating potential for CFT. Further research is needed to explore the application of CFT in treating body image concerns and mitigating the role of stigma in eating disorder care, to better inform practice.

Upon reflection of the search process, some papers used alternative terminology that was not initially included, such as "weight and shape concerns", “weight bias”, “anti-fat bias”, etc.; therefore, some searches may have been limited due to the wide range of terminology used across services and measures. The included studies were predominantly female-focused, centring on young to middle-aged women from Western regions [42–49], and favoured group interventions in practice [43, 49]. Due to the limited scope of available research, it’s unclear whether this is due to this being the modal population in those eating disorder services included, whether this subgroup is more open to engaging with this type of treatment, or whether the group vs individual element played a role; this benefits consideration when introducing group CFT interventions with this subgroup of eating disorder patients. This demographic bias limits the generalisability of findings across different genders, age groups, and cultural backgrounds. Although the studies encompass various eating disorders, clinical trials predominantly focus on Binge Eating Disorder (BED) patients [43, 49], leaving gaps in understanding the applicability of CFT for other conditions. In addition, many of the studies included were conducted without a control group, which limits our understanding of how the treatments operate differently from TAU [52].

What we can see from the studies that have currently been piloted is that CFT treatment for eating disorders is becoming more established in a group-context; this has implied benefits for further challenging the role of shame, as this adds an additional layer of exposure as well as normalising vulnerability in treatment [17]. Group settings may amplify the benefits of CFT by providing a supportive environment where individuals can share experiences, reduce feelings of isolation, and collectively work on self-compassion [17]. This builds upon previous literature detailing the benefit of group interventions in eating disorders [53–55].The group-based CFT interventions in this study [43, 49] show reductions in feelings of shame and eating disorder symptoms, including decreased body dissatisfaction; it’s unclear whether this is due to the group setting due to a lack of available research for 1:1 treatment comparison. There is a noticeable gap in research regarding the impact of individual CFT interventions on body image issues within eating disorder treatment. There is also a lack of a standardised approach, with the 2 aforementioned studies using different approaches to group-based CFT treatment. Establishing a standardised approach for CFT in both group and individual treatment would assist in the replicability of treatment and addressing this issue.

Whilst this study did not fully align with the specific aims of this scoping review, it provided valuable insight into how CFT may be applied more broadly, as a standalone treatment, to treating eating disorder symptoms. Vrabel et al.’s [56] study utilised a randomised controlled trial study design to compare CFT for Eating Disorders (CFT-E) with CBT in treating eating disorder pathology. Both studies showed significant improvements in reducing eating pathology and improving psychological well-being – however, CFT-E showed better long-term outcomes, with changes being maintained 1-year post-treatment, for those with a history of childhood trauma. Due to the total EDE-Q score being used opposed to the subcategories, it’s not possible for us to comment on the role this treatment played in addressing body image concerns specifically. However, the key theme of this study is in highlighting the importance in tailoring interventions for individuals, as CFT-E has shown to be an appropriate option for patients with a trauma history. This research also provides insight into the broader role and applicability of standalone CFT in eating disorder treatment, as other studies included in this scoping review were unable provide this perspective. Future research may benefit from looking at the breakdown of EDE-Q scores when utilising this treatment, to see how different elements of eating disorder pathology respond, and also whether results are still applicable to a control group without a trauma background.

The studies included provided some insight into how CFT is currently being utilised for eating disorder treatment, but also in aiding comparisons between how different types of eating disorders respond to compassion as part of treatment. BED and BN patients are reported to show more symptom changes with CFT compared to those with AN [42–49]. This disparity may be attributed to the distinct cognitive patterns and emotional experiences associated with each disorder. BED and BN are often characterised by episodes of loss of control and subsequent guilt, which are influential factors when considering interventions targeting self-compassion and reducing self-criticism [57]. In contrast, AN involves a more entrenched fear of weight gain and an intense drive for thinness [58], which does not align as readily with CFT’s focus on fostering self-kindness; as reported in the qualitative research, there is a worry about not being “worthy” of self-compassion in this group, and a fear to relinquish efforts in trying to fit in with society’s thin beauty ideal [47]. Additionally, the levels of stigma and types of shame experienced by these patients differ. BED and BN patients report experiencing more external shame, feeling judged by societal standards and stigma surrounding lack of control over-eating [59–61]. AN patients, however, report experiencing profound internal shame rooted in their relentless pursuit of perfection and self-imposed standards, as well as receiving positive reinforcement from peers in society, with weight loss being associated with praise, reinforcing the need for continuous self-monitoring, and observing the self through a 3rd person perspective [62]. It remains uncertain whether this internalised shame may be more resistant to CFT interventions [28] and would benefit from further exploration. Thus, tailored therapeutic approaches considering these cognitive and emotional differences are crucial for enhancing care across eating disorder subtypes.

Building upon the exploration into how the studies addressed the role of stigma, there were some notable similarities and differences. Some studies [46, 49] made explicit references to the impact of stigma (particularly externally from society and internalised shame) relating to eating disorders. They highlighted how stigma was viewed as a barrier to engagement with treatments and that compassionate interventions may help mitigate this by reducing self-criticism. Additionally, Ferreira et al.’s study touches upon the role of internalised stigma when looking into what may drive body image dissatisfaction and the drive for thinness seen in eating disorders [42], similarly to how Koller et al.’s study looks at the impact of internalising societal ideals on how individual’s view their body, and how it’s important to address this as a part of recovery [48]. With the exception of Kelly et al.’s 2020 study [47], where discussions involving apprehension about developing self-compassion is alluded to potentially being influenced by societal pressures, the discussion on the role of stigma in the remaining few studies is limited [43–45]. Whilst stigma appears to be a central theme in many of the included studies, the extent to which it’s addressed is varied, and the lack of explicit discussions in some studies highlights a gap in fully addressing the role of stigma in eating disorder treatment, especially considering its previous links with body image concerns.

The body of clinical research on CFT for treating body image issues in eating disorder patients remains limited, particularly regarding AN. While the theoretical paper suggested potential benefits and barriers of CFT in addressing the unique cognitive and emotional challenges associated with AN [47], practical application and empirical studies are scarce. This lack of concrete evidence hampers the development of comprehensive treatment guidelines and limits the integration of CFT into standard ED treatment protocols.

Limitations and future research

To address the aforementioned demographic-based gaps, future research should prioritise a more inclusive approach by incorporating 1:1 interventions with CFT to allow for direct comparisons, and including control groups. This could provide more personalised and targeted therapeutic options for those with eating disorders. Expanding the participant pool to include stigmatised sub-groups of individuals with eating disorders who tend to be excluded from eating disorder research is crucial for a comprehensive understanding of eating disorders across diverse populations. This includes males who are often excluded from eating disorder research due to the ‘female-centric’ view of eating disorders and assessment measures which do not account for elements of male body image concerns such as muscular dissatisfaction [63]. Transgender and non-binary individuals, where the research is limited, yet youths have been shown to experience higher levels of body image concerns than cis-gender peers and may require body-gender congruence through gender-affirming social and medical interventions to support eating disorder recovery [64]. In addition to older adults, where limited research has identified unique elements of the body image concerns in older women with eating disorders, such as upward comparisons with more youthful females resulting in increased body dissatisfaction [65]. Additionally, more qualitative feedback from patients can provide deeper insights into their experiences and the nuanced effectiveness of interventions, as seen in this study where the worries of meeting society’s “thin-ideal” and whether they’re worthy of compassion provided some insight into potential treatment barriers [47]. Furthermore, exploring research from non-Western countries is essential, as cultural differences have been shown to impact body image perceptions and eating disorder stigma [66]. This broader scope will enhance the applicability and cultural sensitivity of treatment approaches worldwide.

Current studies, primarily focusing on group CFT interventions [43, 49], show promise in addressing body dissatisfaction and challenging stigma than can arise from different eating disorders. However, the lack of control groups and application of CFT as a standalone intervention limits current understanding of its use in treating body image concerns in eating disorder patients. To build a robust evidence base that can inform future treatment guidelines, there is a pressing need for more extensive and diversified research. This includes clinical trials examining individual CFT interventions with control groups for comparison, studies on a broader range of ED subtypes, and research involving diverse demographic groups. Expanding the scope of CFT research would be crucial to support its adoption as a mainstream treatment option in ED services, providing wider treatment options for personalised care.

It should be noted that this scoping study is limited to the availability of currently published research; individual services may be delivering variations of CFT or compassion-focussed treatments for eating disorders to target body image concerns, but may not have published their results. The existence of this grey literature, including the aforementioned unpublished studies, but also including items such as conference abstracts or government reports, limits our ability to draw definitive conclusions since we do not have all of the information available to us [67, 68]^. Finally, whilst it’s important to acknowledge the potential role of publication bias in the studies included, we cannot be certain of the extent to which this may have affected any of the conclusions drawn upon [69].

Conclusion

In conclusion, the current landscape of research on Compassion-Focused Therapy for eating disorders reveals both promising insights and significant gaps. Studies to date predominantly involve young to middle-aged women from Western regions, with a wider prevalence of Binge Eating Disorder patients. Group interventions using CFT have shown some links in addressing feelings of shame and body dissatisfaction – it’s unclear what the specific role of the communal aspect of therapy is in this circumstance due to a lack of 1:1 interventions to compare with. Additionally, the studies utilising CFT [43, 49] demonstrate changes in body image concerns, a critical issue in eating disorder populations. A key theme across the included studies involves the role of self-compassion as a potential mitigating factor for stigma around body image in eating disorder patients.

There appears to be a lack of standardised approaches, and minimal exploration of individual and standalone CFT interventions concerning body image issues in eating disorders. Theoretical discussions highlight the potential role of CFT in addressing the unique cognitive and emotional challenges in disorders such as AN, as well as giving insight into potential barriers [47], but empirical practice studies are limited. This gap underscores the need for extensive, diversified research to establish a robust evidence base. Future studies should prioritise inclusive participant demographics relating to all genders, as well as older populations, to further reduce the stigma that eating disorders only apply to one particular demographic. Additionally, qualitative feedback from patients and cross-cultural research can provide deeper insights and enhance the cultural sensitivity of treatment approaches.

Expanding the scope of research on CFT, particularly individual interventions and their application across various eating disorder subtypes, is crucial. Such efforts will inform future treatment guidelines and support the integration of CFT as a mainstream, evidence-based option in eating disorder services. Ultimately, a more comprehensive understanding and application of CFT could lead to more personalised treatment options focusing on fostering greater self-compassion, a potential mitigating factor for stigma and shame associated with eating disorders.

Author contributions

S.V.D and F.C wrote the main manuscript text and S.V.D prepared Fig. 1, tables 1, 2 and 3, and supplementary information documents. All authors reviewed the figures, tables, and manuscript.

Funding

This study was not funded.

Data availability

Data is provided within the manuscript and tables 1, 2 and 3.

Declarations

Ethical approval and consent to participate

This scoping study was considered a non-human subject’s research and did not require consent to participate. Human Ethics and Consent to Participate declarations: not applicable.

Consent for publication

Consent for publication was not needed for this review study.

Competing interests

The authors declare no competing interests.