The Compassionate Mind for the Long Road
: Acceptability and feasibility of a self-compassion- based intervention for treating comorbid psychological distress in Type 2 Diabetes

Student thesis: Doctoral ThesisDoctor of Philosophy


Diabetes is a multifaceted metabolic chronic condition estimated to affect 4.7 million people in the UK, and 90% of those cases are Type 2 Diabetes (T2D). T2D is distinguished by chronically high blood glucose, and its treatment requires balancing blood glucose levels to the healthy range set by the general population. Thus, people with T2D need to integrate a complex set of self-care behaviours into their daily lives to prevent worsening of the condition. Moreover, it is estimated that approximately 40% of people with T2D report experiencing comorbid mental health conditions, which may result in non-adherence to treatment and decreased quality of life (QoL). Therefore, appropriate management psychological distress (an umbrella term reflecting depression, generalised anxiety, and diabetes distress) in people with T2D is crucial.

Currently available psychological treatments, namely cognitive behavioural therapy, for comorbid psychological distress are beneficial for some people with T2D, but not everyone. There is a particular need for psychological treatments that can effectively target self-criticism which may be common in people with T2D and impact on psychological distress. Recent research in other long-term conditions suggests that adopting a compassionate and kinder approach to oneself may have promise for the treatment of comorbid psychological distress in T2D. However, there is currently limited research into the application of self-compassion for managing psychological distress in diabetes. Therefore, this PhD project aimed to explore self-compassion as a novel treatment target for managing comorbid psychological distress in T2D. To this end, the project involved a systematic review, cross-sectional and longitudinal studies, and a feasibility randomised controlled trial.

Study 1: Preliminary database searches indicated that there was only one randomised controlled trial (RCT) exploring a self-compassion-related therapy in diabetes at the time. Accordingly, the first study applied a broader focus and systematically reviewed the available literature to understand how self-compassion-related therapies have been applied in chronic physical health conditions (CPHCs). Fifteen RCTs (N = 1,190), including seven different CPHCs and eleven types of therapies, were identified in systematic searches of five major databases from 2004 to March 2019. Results suggested that nearly all included therapies were associated with medium to large effect size improvements in self-compassion, indicating that heterogeneous psychotherapeutic approaches may be similarly effective for targeting self- compassion. Results also indicated that the included treatments were associated with significant improvements in psychological distress and physiological outcomes. Only one RCT investigated the Mindful Self-Compassion Course (MSC) for people with diabetes. Results of this trial found that the MSC was associated with significant improvements in self- compassion, depression, diabetes distress and haemoglobin A1c. Taken together, the review results suggest that treatments that promote self-compassion may be promising for CPHCs, but research in T2D is needed.

Study 2: To further build the evidence on self-compassion in T2D, study two investigated the shared and unique associations between self-compassion and a related construct, psychological inflexibility – the key process of Acceptance and Commitment Therapy (ACT), with psychological distress and quality of life outcomes. A cross-sectional, online questionnaire study included 173 adults with T2D from November 2018 to July 2020. Bivariate analyses demonstrated that self-compassion and psychological inflexibility were strong correlated (r = -0.69). Hierarchical regression analyses found that self-compassion and psychological inflexibility were both uniquely associated with depression. However, only psychological inflexibility was uniquely associated with anxiety and diabetes distress. In addition, only self-compassion was uniquely associated with quality of life. The results indicate that while there is overlap between self-compassion and psychological inflexibility, they are unique constructs to a degree and may be differentially associated with psychological distress and QoL outcomes in T2D.

Study 3: To address the limitations of the cross-sectional design of study two, a longitudinal study was conducted to explore the shared and unique contributions of self-compassion and psychological inflexibility to psychological distress and QoL outcomes in T2D over time. Participants who took part in the cross-sectional study were also invited to complete the six-month and 12-month follow-ups between November 2018 and May 2021. Bivariate correlations also suggested strong correlations between self-compassion and psychological inflexibility over time (rs = -0.69, -0.80, and -0.70; ns = 153, 69, and 34, respectively). Hierarchical multiple regression models found that baseline psychological inflexibility uniquely predicted depression at six-months, anxiety at six- and 12-months, and QoL at 12-months after controlling for baseline psychological distress levels. Self- compassion did not predict any psychological distress or QoL outcomes over time. ACT may be well-suited to improve psychological distress in T2D given its explicit focus on fostering psychological flexibility, although treatments targeting self-compassion may also target psychological flexibility given the strong association between these variables. However, replication of the current findings is needed given the small sample size and high proportion of missing data at follow-up.

Study 4: Bringing together findings from the earlier studies, the PhD researcher developed a five-week, self-guided, online training called Acceptance, Commitment, and Self-Compassion Based Treatment in Diabetes (ACSBT-D), integrating the MSC and ACT. The treatment was enhanced by the involvement of six people with T2D whose feedback shaped the treatment materials and delivery format. An online, parallel-groups randomised- controlled feasibility trial (N = 33) with a waitlist control was conducted to understand the feasibility of a larger trial of ACSBT-D among people with T2D. Qualitative interviews were nested within this trial to further ascertain acceptability. Treatment completion (47.37%) and trial retention rates (39.39 and 21.2% for 5- and 9-week follow-ups, respectively) indicated that a larger trial of ACSBT-D is not feasible in its current form. Findings from this study can aid further developments of treatment and trial methods for future research into self- compassion and ACT focused treatment for managing psychological distress in T2D.

Discussion: This thesis provides novel evidence on the shared and unique contributions of self-compassion and psychological inflexibility to depression, anxiety, and diabetes distress in T2D. The findings suggest that integrating self-compassion techniques in ACT may be beneficial, but further research is needed to optimise treatment integrating ACT and self- compassion in this population. Greater understanding of the role of self-compassion and psychological flexibility and treatments targeting these processes in a diversity of people may ultimately improve the lives of people with T2D for the long road.
Date of Award1 Dec 2022
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorWhitney Scott (Supervisor), Joanna Hudson (Supervisor) & Lance McCracken (Supervisor)

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