Having one or multiple diagnosable mental health or psychiatric conditions (hereinafter referred to as MH problems), such as externalizing disorders (e.g., attention-deficit hyperactivity disorder and conduct disorder) or internalizing disorders (e.g., depression and anxiety disorders) during adolescence is difficult for the adolescents and their families. The worldwide prevalence of these MH problems is about 10–20 % (1), and it continues to increase (2). Additionally, a substantial proportion of these problems persist into adulthood (3).
In addition to the social and educational problems they encounter, children experiencing MH problems are at higher risks of being stigmatized, such as being stereotyped and discriminated against, than their peers with other (or no) health problems (4). Feelings of shame and self-stigmatization (internalized stigma adopted from others) might interfere with their recovery from MH problems (5) and influence the extent of their MH impairments and chronicity (6, 7).
Furthermore, many adolescents diagnosed with MH problems do not disclose their conditions to others (6, 7), which might hinder them from obtaining social support from their families, peers, and others. Adolescents who believe their MH problems are lifelong conditions tend to have relatively high levels of self-stigma and perceive that they have relatively less control over their difficulties. High levels of shame and self-criticism have been found in samples of adults experiencing MH problems (5, 8-13). However, there is little research on self-criticism among adolescents experiencing MH problems.
Adolescents with one or more MH problems need more support than their healthy peers, and to support them and deal with their problems might be challenging and stressful for their parents (14). Parents of children who experience MH problems tend to perceive themselves as not good enough (15) or believe that they contributed to the causation, exacerbation, or continuation of their children’s MH problems (16). Parents tend to feel isolated in their parenting struggles and unsupported by the other parent, the child’s school, and/or healthcare professionals (15). Interventions are needed to help parents manage their stress and enhance their sense of agency and trust in their abilities to support their children’s development and success (17).
The impact and long-term negative consequences of MH problems during adolescence highlight the need for effective early treatments. Compassion-focused therapy (CFT) was originally developed to help people experiencing chronic and complex MH problems and those experiencing high levels of shame and self-criticism to cultivate a compassionate care orientation toward themselves and others (18, 19). CFT is an integrative multi-modal therapy based on evolutionary psychology, attachment theory, neuroscience, and cognitive behavior theory. An essential aspect of CFT is compassionate mind training to help individuals to experience warm, positive feelings and support within themselves.
Self-compassion refers to an open and caring disposition toward oneself while experiencing an unpleasant event rather than a self-judging and self-critical attitude (20). Self-compassion includes an ability to balance one’s emotions during difficult times and an acknowledgment that struggling is part of the human experience. Adolescents who score high on self-compassion tend toward lower perceived stress (21), anxiety, and depression (22) in non-clinical studies. The relationships between self-compassion, perceived stress, and psychological wellbeing also have been found among adults (23). Parents with relatively high levels of self-compassion have been found to be less critical and to use fewer distressed reactions to cope with their children’s emotions than those with lower levels of self-compassion (24). CFT is considered a promising approach to easing various psychological disorders (25-28), but, since CFT is a relatively new psychotherapy, the evidence base regarding its efficacy is insufficient. Kirby et al.’s meta-analysis (26) of compassion-based interventions included papers on 21 randomized clinical trials (RCT), but only three were on CFT, and only one of those papers (29) reported on a clinical sample. Braehler and colleagues (29) compared a group receiving CFT plus treatment as usual (TAU) (
CFT studies not combined with TAU or cognitive behavioral therapy are scarce, and most of them did not use control groups (25, 28). One exception is a nonrandomized transdiagnostic group at a mental health service in Ireland that treated patients with either group-based CFT (
In sum, more research on stand-alone CFT implemented in clinical settings is needed. Studies conducted to date mostly included small samples without control groups, making generalization of findings problematic. It also is necessary to explore whether group-based CFT might help adolescents experiencing MH problems and their parents. CFT seeks to help people face their challenging feelings with courage, wisdom, warmth and care. This can help adolescents and their parents to be more compassionate toward themselves, rather that blaming themselves for the difficulties in life. The present study’s first aim was to explore whether group-based CFT would help improve self-compassion and reduce stress in a transdiagnostic group of adolescents experiencing complex MH problems and their parents. Since CFT was specifically developed to increase the capacities to experience compassion, self-compassion was chosen as primary outcome. The second aim was to compare the levels of self-compassion and stress participants receiving group-based CFT with adolescents and their parents receiving TAU.
The Regional Ethical Review Board in Gothenburg, Sweden approved this study (Number: 330-16). Participants were assured of data confidentiality, and permission to use data for reports that ensured the protection of the participants’ identities were obtained from all participants through informed written consent to participate, and their parents consented to their and their children’s participation.
The sample consisted of 43 adolescents (CFT,
This study was part of a larger research project that analyzed qualitative data on participants’ CFT experiences, and these results will be presented in two additional papers—one unpublished article reporting on qualitative data on adolescents’ experiences, and the other a published article about parents’ experiences with group-based CFT (37). The Transparent Reporting of Evaluations with Non-randomized Designs (TREND) statement was followed (38). The participants were recruited continuously from January 2017 until October 2018. Five CFT groups were observed, each of which had a minimum of three adolescents.
The treatment team determined eligibility during intake based on the inclusion and exclusion criteria. During intake, all individuals who met the inclusion criteria were asked if they wanted to receive group-based CFT. Individuals who did not want to participate in the group-based CFT were asked if they wanted to be in a control group receiving TAU. Figure 1 illustrates the enrollment and attrition process.
Although the study was intended as a randomized controlled clinical trial of CFT, only 30 adolescents volunteered for the group-based CFT, of which 19 (63 %) completed the questionnaires post treatment. Since blinded random assignment of volunteers would have created groups considered too small for this study, all of the volunteers were assigned to the group-based CFT. During the eight-week CFT treatment period, nine participants had no other MH support, four participants had one medical follow-up with a nurse or psychiatrist, and six participants had one meeting with a therapist or social worker for individual (e.g., at school) or family (with a parent) meetings.
The 24 volunteers for the control group who remained in the study until the end received TAU, which included cognitive behavioral therapy (CBT), systematic psychological treatments, clinical assessments, and psychosocial support. The participants in the control group were limited to TAU throughout the study period. Systematic psychological treatment refers to a mix of clinical assessment, network meetings with school and other support teams, and psychological treatments such as CBT, psychodynamic therapy, or family therapy.
A pretreatment questionnaire about self-compassion and perceived stress was distributed to all the participants (CFT = 83, TAU = 117). The questionnaire was distributed again to the 47 CFT participants during their last CFT session and to the 73 remaining TAU participants eight weeks after their TAU treatments began, presented in Table 2 as post treatment. A six-month follow-up questionnaire was distributed, but response rate was low (CFT group: adolescents,
The intervention was adapted and developed from the transdiagnostic CFT approach (18, 39). The feasibility and appropriateness to the participants of this group-based CFT intervention was assessed in a pilot study, which included six parallel CFT groups from August 2015 through December 2016, and the intervention was constantly adapted by considering feedback from the participating adolescents and parents. The most notable adjustments were lengthening the intervention from five to eight sessions and reducing the proportion of didactic teaching in favor of discussions, role play, and practical compassion work, such as making bracelets featuring a compassion statement (CFT adolescent group). Based on the results of the pilot study, we planned to include 34-36 participants in each CFT and TAU group, to detect an effect size of 0.5 with a power of 80 %.
The parents’ group leader was a clinical psychotherapist, and a clinical psychologist and psychotherapist (this paper’s first author) delivered the adolescents’ CFT, except for one group, which was led by a CFT-trained social worker. All of the group leaders completed CFT training at the Compassionate Mind Foundation in the United Kingdom. Two assistants not trained in CFT, but with significant experience in psychiatry and with academic backgrounds, provided support.
The group-based CFT sessions were eight parallel sessions lasting about two hours each. The adolescent and parent groups met at the same time but separately. The sessions followed the CFT principles, but they were adapted to meet the participants’ needs. The intervention had two phases. First, psycho-education about humans’ “tricky brains” and ways that we can understand negative threat emotions in an evolutionary perspective were covered (18, 40). The participants were encouraged to reflect on the balance in their threat, drive, and safeness system. The second phase was about attending to and perceiving the reasons for emotions and learning about the ways people are differently organized by various emotions. The subjects engaged in mindfulness and compassion-based exercises, such as soothing breathing, creating a safe place, visualizing a compassionate self-image, and exploring the role of one’s self-criticism. The structure and content of the sessions were the same for parents and the adolescents, and they were encouraged to complete homework assignments together at home.
Data on age and gender were obtained from self-report single items.
Responses to the 12-item Self-Compassion Scale–Short Form (SCS-SF) were used to measure self-compassion (41). The response options are on a five-point scale ranging from 1 =
The Swedish version of the Perceived Stress Scale (PSS) (43, 44) was used regarding pretreatment and post-treatment perceived stress. The 14-item PSS concerns the perception of life as unpredictable, uncontrollable, and overwhelming during the previous month. Responses were on a five-point scale from 0 =
The psychometric properties of the Swedish 14-item PSS had strong internal consistency in two Swedish adult samples. In a sample of women and men (
The statistical analyses were performed using SPSS (ver. 25). Descriptive statistics were used to assess the normality of the distributions of scores and the means of the SCS-SF and PSS scores. Paired samples
Table 1 presents the descriptive statistics on the adolescents’ characteristics, MH diagnoses, the TAU adolescents’ types of treatment, parents’ ages, and mean number of sessions. There was no statistically significant difference between the CFT and TAU groups regarding age. The CFT parents received significantly more sessions than the TAU parents received, but the difference in the adolescents’ numbers of sessions was not significantly different between the groups.
Characteristics of the adolescent participants and their parents.
Characteristic | CFT Adolescents ( | TAU Adolescents ( | |
---|---|---|---|
Mean age (years) | 15.9 | 15.5 | ns |
Gender; n (%) | |||
Female | 17 (89.5) | 19 (79.2) | |
Male | 2 (10.5) | 3 (12.5) | |
Other | 2 (8.3) | ||
Mean number of sessions (min–max) | 6.5 (4–8) | 6.0 (1–14) | ns |
TAU treatment type | |||
CBTa, | 8 | ||
Systematic psychological treatment, | 12 | ||
Clinical assessment and psycho-social support, | 4 | ||
Pretreatment psychiatric diagnoses, | |||
Depression | 1 | 2 | |
Depression, PTSDb, and self-harm | 1 | ||
Depression and anxiety disorder | 7 | 8 | |
Depression and GADc | 1 | ||
Depression, psychological problems, and behavioral problems related to alcohol misuse | 1 | ||
Depression, anxiety disorder, and self-harm | 2 | 1 | |
Depression, anxiety disorder, and learning disabilities | 1 | ||
Depression, anxiety disorder, and PTSD | 1 | ||
Depression, anxiety disorder, self-harm, and | 2 | ||
ADHDd/ADDe | |||
OCDf | 1 | ||
OCD, GAD, and self-harm | 1 | ||
Anxiety disorder (unspecified) | 6 | ||
Anxiety disorder and autism | 1 | ||
Anxiety disorder and ADHD | 1 | ||
Suspect autism and specified problems related to the family | 1 | ||
Panic disorder with agoraphobia | 1 | ||
Reaction to severe stress | 1 | ||
Suspected PTSD | 1 | ||
Mixed disorder of conduct and emotion | 1 |
CFT mothers ( | TAU mothers ( | ||
---|---|---|---|
Mean age | 44.2 | 46.0 | ns |
Mean number of sessions (min–max) | 5.9 (3–8) | 3.6 (1–11) | 0.004 |
CFT fathers ( | TAU fathers ( | ||
---|---|---|---|
Mean age | 49.4 | 48.4 | ns |
Mean number of sessions (min–max) | 6.3 (4–8) | 3.5 (0–7) | 0.013 |
Table 2 indicates there were no significant differences between the pretreatment and post-treatment mean scores on either the SCS or PSS for the CFT adolescent group or the TAU adolescent group. Among the four parent groups, only the TAU mother group was significantly different post-treatment, and these mothers experienced a significant mean increase in self-compassion (33.9 increased to 37.1).
Pretreatment-posttreatment differences in SCS and PSS groups
Group | SCS Pre Mean (SD) | SCS Post Mean (SD) | PSS Pre Mean (SD) | PSS Post Mean (SD) | ||
---|---|---|---|---|---|---|
CFT adolescents ( | 27.9 (6.4) | 28.8 (6.4) | 0.18 (0.72) | 30.8 (7.6) | 29.5 (6.3) | 0.34 (1.0) |
TAU adolescents ( | 26.4 (6.5) | 27.8 (7.3) | 0.31 (1.0) | 30.9 (5.8) | 28.8 (8.4) | 0.08 (0.48) |
CFT mothers ( | 35.2 (6.8) | 38.7 (6.5) | 0.08 (0.50) | 25.3 (5.1) | 22.8 (5.6) | 0.18 (1.0) |
TAU mothers ( | 33.9 (9.8) | 37.1 (9.4) | 0.02 (0.102) | 24.7 (7.4) | 23.3 (7.2) | 0.21 (1.0) |
CFT fathers ( | 40.5 (6.7) | 40.2 (9.0) | 0.87 (1.0) | 18.7 (4.5) | 19.4 (5.7) | 0.57 (1.0) |
TAU fathers ( | 43.3 (9.3) | 42.9 (9.1) | 0.76 (1.0) | 18.0 (5.3) | 19.8 (5.8) | 0.12 (0.72) |
Change score differences between CFT and TAU adolescent, mother, and father groups
Variable | CFT adolescents ( | TAU adolescents ( | Effect size | |||||
---|---|---|---|---|---|---|---|---|
Mean (SD) | 95% CI | min-max (range) | Mean (SD) | 95% CI | min-max (range) | |||
SCS change | 0.9 (2.6) | −0.4, 2.1 | −3-8 (8) | 1.4 (6.9) | −1.4, 4.3 | −12-15 (27) | 0.73 (1.0) | 0.10 |
SCS improved, | 10 | 15 | ||||||
PSS change | −1.3 (6.0) | −4.2, 1.6 | −16-8 (24) | −2.1 (5.7) | −4.5, 0.3 | −10-7 (17) | 0.66 (1.0) | 0.14 |
PSS improved, | 10 | 15 |
CFT mothers ( | TAU mothers ( | Effect size | ||||||
---|---|---|---|---|---|---|---|---|
Mean (SD) | 95% CI | min-max (range) | Mean (SD) | 95% CI | min-max (range) | |||
SCS change | 3.5 (7.9) | −0.5, 7.6 | −12-19 (31) | 3.2 (7.0) | 0.6, 5.9 | −9-21 (30) | 0.87 (1.0) | 0.04 |
SCS improved, | 12 | 19 | ||||||
PSS change | −2.5 (7.3) | −6.2, 1.3 | 15-9 (24) | −1.4 (6.1) | −3.7, 0.8 | −15-10 (25) | 0.60 (1.0) | 0.17 |
PSS improved, | 11 | 17 |
CFT fathers ( | TAU fathers ( | Effect size | ||||||
---|---|---|---|---|---|---|---|---|
Mean (SD) | 95% CI | min-max (range) | Mean | 95% CI | min-max (range) | |||
SCS change | −0.4 (7.3) | −5.3, 4.5 | −12-12 (24) | −0.4 (6.3) | −3.4, 2.6 | −13-11 (24) | 0.49 (1.0) | 0 |
SCS improved, | 6 | 8 | ||||||
PSS change | 0.7 (3.9) | −1.9, 3.3 | −4-8 (12) | 1.8 (4.7) | −0.5, 4.0 | −4-14 (18) | 0.76 (1.0) | 0.25 |
PSS improved, | 5 | 6 |
There was no significant difference between the CFT and TAU adolescent groups in the extent to which self-compassion changed (
The results for the mothers and fathers were similar to those for the adolescents. There were no significant differences in SCS or PSS change scores between the CFT mothers and TAU mothers, with an effect size of 0.04. Moreover, there were no significant differences between the CFT fathers and the TAU fathers in SCS change (effect size = 0) or PSS change (effect size = 0.25).
This study’s results revealed no significant differences within or between group-based CFT and TAU treatments regarding self-compassion and perceived stress after eight weeks of CFT or TAU intervention (except for the control group mothers, whose mean self-compassion score significantly increased), and the effect sizes were small (
Ten of the 19 CFT adolescents and 15 of the 24 TAU adolescents who completed the sessions had higher self-compassion scores and lower perceived stress scores after the treatment; however, those results were obscured by the effects on the means of the scores that did not change or decreased. Therefore, the effect sizes were weak on both measures. The small effect sizes in the present study were anticipated because of the short treatment period for adolescents experiencing complex MH problems. The results are in line with a previous finding, which showed that efficacy of psychotherapy when compared to TAU is limited with an effect size of 0.30 or below (46). However, according to a systematic review of adolescent depression (47), most studies used clinicians’ measures of symptom change, while patients’ and parents’ perspectives, as well as their personal growth, interpersonal relationships, and school performance were not assessed. A qualitative study of parents’ experiences showed that the CFT intervention enabled parents to find their agency and inner confidence to support their children (37). The parents found it easier to care for their children, when they were able to care for themselves. This qualitative study suggested that CFT could be a promising approach to support parents of young people experiencing MH problems. Future studies need to explore the factors affecting lack of participation or withdrawal of participation in both CFT and TAU conditions, in order to develop interventions tailored to the needs of the patients.
CFT was developed to reduce self-criticism and shame among individuals with multiple MH problems (31), which could help adolescents who experience complex MH problems. In separate analyses, we found that some of the adolescents in the CFT group found the intervention difficult, particularly regarding mentalizing with themselves and/or others and trying to identify various emotions. Some adolescents obtained lower scores on self-compassion after the treatment, which might be related to their lack of awareness of their degree of self-criticism before CFT. Furthermore, some patients had difficulties with the abstract content of the CFT program. That finding supports McFarlane’s results on compassionate mind training in a school setting, in which some adolescents were helped, whereas others were challenged (48). More research is needed to help us understand the characteristics of those who benefit from CFT and those who might be overwhelmed by it. A single-subject design might be particularly appropriate in this case.
Regarding the parents, the fathers scored higher on SCS and lower on PSS than the adolescents or the mothers on the pretreatment and post-treatment tests. This finding supports previous studies’ findings that men are more self-compassionate than women (49).
Conducting research in applied contexts is challenging, and the present study has a number of limitations such as low sample sizes, insufficient description of the content in the TAU condition, and risk of self-selection bias. The nature of sample selection made it impossible to randomly assign the adolescent participants to the treatment and control groups because only few adolescents volunteered for the group-based CFT intervention. Furthermore, the response rate for the post-treatment questionnaire was low (CFT = 57 % (total
The present study conducted a nonrandomized clinical trial to examine the effects of an eight-week, group-based CFT on a sample of vulnerable adolescents. No previous studies have examined whether CFT is a helpful psychotherapy method in adolescents having mental health problems, and therefore this study contribute to the field. Adolescents with mental health diagnoses have complex problems related to their developmental stage. Further studies are need to investigate whether a compassion-focused approach can help these children and their parents to cope with their challenging situations. There were no significant changes in self-compassion or perceived stress after treatment in the experimental or control group of adolescents or their parents, and there were no differences between the experimental and control groups (except for the control group mothers, whose mean self-compassion score significantly increased). This suggests that some patients seem to benefit from group-based CFT in ways similar to the benefits of specialized therapeutic approaches. However, some patients might need a more individualized approach. Further research into the utility of CFT for adolescents with MH problems and their parents, as well as the long-term clinical effects of CFT for this group is needed.
Group-based CFT for adolescents experiencing complex MH problems and their parents may be a complement to current psychiatric treatments. For the adolescents, individual sessions between the group sessions, may be necessary to capture individual needs, and also to detect any adverse effects of the treatment.
Some participants found the abstract content of the CFT program including visualizing and mentalizing hard. On the other hand, the group-based format made it possible for the participants to share their thoughts, and listening to others can be valuable for those who had mentalizing difficulties.