The Contribution of Shame to Eating Disorder Treatment Outcomes in a Community Mental Health Clinic

Abstract

ABSTRACTObjectiveShame is a powerful self‐conscious emotion that is often experienced by individuals with eating disorders (EDs). While the association between EDs and shame is well‐established, there is limited research investigating the contribution of pre‐treatment shame to clinical outcomes.MethodParticipants (N = 273) received outpatient cognitive‐behavioral therapy for eating disorders (CBT‐ED). We investigated pre‐treatment shame as a predictor of dropout and as a moderator of change in ED psychopathology and clinical impairment from pre‐treatment to post‐treatment. We also explored the potentially moderating roles of body mass index, ED diagnostic category, and co‐occurring anxiety and depression diagnoses.ResultsShame improved substantially (d = 1.28) despite not being explicitly targeted in treatment. Pre‐treatment shame did not predict treatment dropout. Individuals high in shame started and ended treatment with higher ED symptoms and impairment than those with low shame. The contribution of pre‐treatment shame on the degree of change in symptoms/impairment depended critically on whether analyses controlled for pre‐treatment symptoms/impairment. When those were controlled, high pre‐treatment shame was associated with substantially less improvement in ED symptoms and impairment. There was some evidence that ED diagnosis and co‐occurring depressive diagnoses may moderate the relationship between shame and treatment outcome. Changes in shame were positively associated with changes in ED symptoms and clinical impairment.DiscussionA high level of shame at pre‐treatment is not a contraindication for CBT‐ED as good therapeutic outcomes can be achieved. However, outcomes may be enhanced among individuals high in shame by offering adjunctive interventions that explicitly target shame.