Self-critical individuals are more likely to become and remain depressed (Blatt, Experiences of depression: Theoretical, research and clinical perspectives, American Psychological Association Press, Washington, DC, 2004). This vulnerability to depression may reflect the association of trait self-criticism with difficulties self-soothing and resisting self-attacks. The current study tested the impact of two self-help interventions designed to reduce depression by improving these two intrapersonal deficits. The first was designed to foster compassionate self-relating whereas the second was designed to foster resilient self-relating. Seventy-five distressed acne sufferers were assigned to one of three conditions: a self-soothing intervention, an attack-resisting intervention, or a control condition. The interventions consisted of daily imagery-based self-talk exercises inspired by Gilbert’s (Genes on the couch: Explorations in evolutionary psychotherapy, Brenner-Routledge, Hove, 2000) social mentatlities theory and compassionate mind training (Gilbert and Irons, Compassion: Conceptualisations, research and use in psychotherapy, Brunner-Routledge, London, 2005). In two weeks, the self-soothing intervention lowered shame and skin complaints. The attack-resisting intervention lowered depression, shame, and skin complaints, and was especially effective at lowering depression for self-critics. Implications for the treatment of self-criticism and depression are discussed.
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Although we were interested in the impact of our interventions on depression, we chose not to have inclusion criteria specific to depression. This is because we were interested in the effects of our treatments on the depressive symptoms of distressed acne sufferers across levels of depression. We therefore focused on ensuring all participants shared significant levels of acne-related distress (as assessed by the SKINDEX-16) and expected that many of these people would also show elevated depression scores, even if not clinically severe.
Participants were asked to visualize an orange and were slowly guided to imagine all of its sensory features—appearance, touch, smell, and taste. We chose an orange as the object of visualization because we felt this was an emotionally neutral object that would not interfere with the subsequent exercises or differentially prepare participants for the particular intervention-specific imagery they would be asked to engage in.
The assessment portion of the slideshow prompted participants to look at themselves in the mirror and to then complete a record form taken from Gilbert and Irons’ (2005) chapter on CMT. Similar to standard cognitive therapy assessments, the form asked individuals to report on variants of automatic thoughts—namely, the thoughts and feelings they have about themselves (internal shame) and the thoughts and feelings they believe others have about them (external shame). They were then asked to rate a series of emotions, taken from PANAS-X, to identify how they felt while reflecting on their acne.
Given that our interventions were self-help nature, there was no therapist present to individualize our intervention exercises to each participant. To overcome this limitation, we tried as much as possible in our instructions to encourage individual adaptations of the exercises, staying within the assigned format, to facilitate their targeting the personal experiences of the participant. For instance, our assessment form asked individuals to report on their own thoughts and feelings, and our intervention asked them to write their own self-letter and self-statements.
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Sample Letter Provided in Self-soothing Condition
I recognize that you are very upset right now about your acne, and it is okay to feel that way. I understand why you feel distressed and I would feel the same way if I were in your position. Please do not blame yourself for having acne because it is not your fault and it does not mean that you are flawed. I know you think that everyone stares at your acne when you go grocery shopping but this may not be the case. Remember that good, worthwhile people will not focus on your acne but rather focus on who you really are and your positive qualities. People who matter will feel comfortable around you no matter how you look. I care about you and will always be kind and compassionate to you regardless of the condition of your skin. Please try to accept how you look and remind yourself that you deserve to be loved as much as everyone else. It is OK, though, to feel upset and hopeless at times; all people do at certain times of their life. It is OK to not be perfect, physically or emotionally. What would you say to a friend in your position? You would probably empathize with their suffering, and let them know that you care about them and love them and want to be around them regardless of how they look.
Sample Letter Provided in Attack-resisting Condition
I’ve been letting you attack me for some time now, and I’m not going to let you continue to put me down in the way that you do. You make me feel horrible and say things that are probably not even true. I’m going to stop believing what you say, because I can be logical and see the falsehoods in what you say to me. Just because I have acne, it doesn’t mean I should be told to hide my face or that people won’t like me. I have no reason to believe these things so stop telling me them over and over. I am confident that behind my skin, I’m a valuable person who has a lot of worth. I will not let you beat me down and make me miserable. From now on, I’m going to stand up for myself when you say negative things to me. I’m smart enough to see that you have no evidence for most of what you say to me and I’m not going to believe it. I also don’t deserve to be treated in the harsh way you treat me, and am strong enough to stop you. You are making me feel bad, and I won’t let you do this to me anymore.
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Kelly, A.C., Zuroff, D.C. & Shapira, L.B. Soothing Oneself and Resisting Self-Attacks: The Treatment of Two Intrapersonal Deficits in Depression Vulnerability. Cogn Ther Res 33, 301 (2009). https://doi.org/10.1007/s10608-008-9202-1
- Personality vulnerability